NHS0022

Written evidence submitted by the British Medical Association

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

1. Summary

1.1   The BMA welcomes the opportunity to respond to the Public Accounts Committee’s inquiry into NHS backlogs and waiting times. The Covid-19 pandemic has significantly worsened NHS waiting lists and created a significant backlog of care.

1.2   Entering the pandemic, the NHS was already under intense pressure. In England alone, the waiting list had reached 4.24 million[1], A&E performance was at then record lows, staff vacancies neared 90,000[2] and primary care was overstretched.

1.3   The first wave of the pandemic resulted in a significant number of hospitalisations which put the NHS under severe pressure. To cope with the pandemic the NHS had to reduce the number of elective procedures, creating an additional backlog on top of the pre-pandemic waiting list. The scale of the elective challenge was worsened by significant delayed patient presentation, and on top of that the pandemic has led to a significant backlog in primary care and delays to outpatient appointments. After the first wave, many elective procedures were again cancelled as the second, worse wave of Covid-19 cases and hospitalisations set in, causing further growth in the backlog. Infection control measures and the ongoing diversion of resources towards Covid-19 services mean that this backlog of care will take even longer to work through as it continues to accumulate.

1.4   The NHS waitlist for elective care now stands at a record 5.83 million patients (as of September 2021)[3], a 32% increase since September 2019 and this does not even include primary care.

1.5   To cut waiting lists and effectively work through the backlog of care, without overburdened already burnout staff, we call on all governments, system leaders, and employers across the UK to:

• Communicate honestly with patients and the public about health service pressures and how long it will take to clear the backlog of care

• Retain existing staff and maximise workforce capacity including by:

• Protecting the health, safety, and wellbeing of staff, including by taking a zero-tolerance approach to violence and abuse and providing PPE that ensures proper protection from infection
• Cutting red tape, remove unhelpful targets and barriers, and reduce unnecessary bureaucratic workload
• Ending punitive pensions taxation rules and taking additional measures to maximise workforce capacity including restrictive immigration rules for international doctors
• Promote responsible public health policies to keep people safe and healthy and help manage demand on services

• Direct resources to where they are needed most to manage health service demand

2. Current position of NHS backlogs and waiting times

2.1   The NHS waitlist for care now stands at a record 5.83 million patients (as of September 2021)[4], a 32% increase since September 2019. There has also been a huge increase (more than 230-fold) in the number of people waiting longer than a year for their care.[5]

2.2   The future for the NHS backlog and waitlists is uncertain and depends on both the demand for healthcare (how many ‘missing patients’ return), as well as NHS capacity to deal with this demand. According to Institute for Fiscal Studies (IFS) projections, if NHS capacity remains below 2019 levels, and over two thirds of patients return, it is likely that waiting lists could more than double over the next three years.[6]

The waiting list for consultant-led referral to treatment

2.3   In March 2020 there were around 4.24 million people on the waiting list for treatment. The waiting list has been growing month on month since May 2020, with the latest data showing a record high of 5.83 million people waiting for treatment as of September 2021.[7]

2.4   1.95 million of these people have been waiting over eighteen weeks, which is three times the number of people waiting over eighteen weeks in September 2019.

2.5   300,566 of these people have been waiting over a year - 230 times more than the number of people waiting over one year in September 2019. This is an improvement from the peak in March 2021, where 436,127 people were waiting over a year for care.

Emergency department attendances and waiting times

2.6   In England, A&E attendances have reached pre-pandemic levels, with 2.17 million patients visiting emergency departments in October 2021, only 0.2% lower than in October 2019.[8]

2.7   121,251 patients spent more than four hours waiting from a decision to admit to admission in October 2021, the highest for any month since records began.[9] 7,059 people had a trolley wait of over 12 hours, almost ten times the number waiting more than twelve hours in October 2019.[10]

2.8   Performance against key waiting time targets has significantly worsened in England with only 73.9% of patients admitted, transferred, or discharged within four hours from emergency departments, a record low.[11]

2.9   These pressures are exacerbated by Covid-19 admissions and deaths remaining unacceptably high, with 7,268 patients in hospital with Covid-19, 900 of whom were in mechanical ventilation beds on 7 December.[12] The emergence of the Omicron variant which early evidence suggests is more transmissible may well add to the pressures the healthcare system is already facing.

Appointments in General Practice

2.10                 GP surgeries across the country are experiencing significant and growing strain with rising demand, practices struggling to retain staff, and patients having to wait longer for appointments. Insufficient investment in the GP workforce does not prevent patient numbers from rising. In fact, despite there being 1,704 fewer fully qualified FTE GPs today than there were in 2015, each practice has on average 1,849 more patients than in 2015.[13]

2.11                 Alongside these long-term trends, GP practices have been at the forefront of the NHS’s response to the Covid-19 outbreak, delivering the vaccine programme whilst maintaining non-COVID care for patients throughout. During the pandemic, to control patient numbers in practices it became necessary to replace some face-to-face appointments with e-consultations – as directed by NHSE guidance. The need to adapt to new technologies and the increased administrative burden it entails has added further pressure, on top of which GPs have been facing growing hostility. This hostility remains, even though most GPs appointments have been face-to-face throughout the pandemic, excluding a two-month period from April to May 2020. As of October 2021, two thirds (64%) of all GP appointments took place face-to-face.[14]

2.12                 The number of standard appointments in general practice booked in October 2021 has risen since September by 1.8 million to 30.4 million[15], while the number of Covid-19 vaccination appointments delivered by practices has increased to 3.5 million. This brings the total number of appointments in October to nearly 34 million which is 3.1 million more appointments than were delivered pre-pandemic in October 2019 (including Covid vaccination appointments).

Diagnostic backlog

2.13                 As of September 2021, 26.1% of patients have been waiting over six weeks for a diagnostic test.[16] Although lower than at the peak of the pandemic, this is substantially higher than pre-pandemic levels, and the national target that no more than 1% of patients should wait more than six weeks.

2.14                 The number of tests being carried out increased to 1.92 million, recovering to pre-pandemic levels. However, given the backlog of care that has accumulated 1.4 million people are now on the diagnostic waiting list – the highest number since records began.[17]

3. The effect that Covid-19 has had on waiting times

3.1   Entering the pandemic, the NHS was already under intense pressure. In England alone, the waiting list had reached 4.24 million[18], A&E performance was at then record lows, staff vacancies neared 90,000[19], and numbers of GPs had been falling.[20]

3.2   The NHS has been operating against a backdrop of chronic understaffing and under-resourcing for many years, long before the pandemic hit. Stubbornly high NHS staff vacancies existed well before Covid-19 (88,347 FTE total staff vacancies in March 2020)[21] largely because of a retention crisis driven by burnout and exhaustion, insufficient funding to train enough staff and poor workforce planning. Thousands of exhausted doctors have told the BMA they are considering leaving the NHS in the next year, as many continue to battle stress and burnout without adequate respite from the exhaustion caused by the demands of the pandemic. While half of respondents (2,099) in the Association’s tracker survey from May 2021[22] said they plan to work fewer hours, 25% said they are ‘more likely’ to take a career break, with a further 21% considering leaving the NHS altogether for another career. This was made worse by punitive pension taxation rules and years of demoralising pay erosion even before the pressures of delivering care during the pandemic.

3.3   Additionally, there has been a reduction of general and acute beds in England, dropping by 13,570 between 2010/11 and 2021/22.[23] The Royal College of Surgeons in England have called for the number of beds to be in line with the OECD average of 4.7 per 1,000 people, nearly double from their estimate of beds in England of 2.5 per 1,000 people.[24] The resourcing and workforce crises for years before the pandemic meant the NHS was wholly unprepared for a major public health crisis.

Delayed patient presentation

3.4   There are significant numbers of ‘missing patients’ that aren’t yet on waiting lists. During the pandemic, much of the care the NHS would usually deliver was reduced or halted, meaning that millions of patients who would have been expected to be referred to treatment were not.

3.5   The BMA estimates that between April 2020 and September 2021, there were 3.98 million fewer elective procedures and 27.22 million fewer outpatient attendances compared to pre-COVID averages, illustrating the potential scale of unmet need.[25]

3.6   These ‘missing patients’ will likely result in larger numbers of patients presenting with worsened conditions requiring more intervention and higher cost treatment.

3.7   Additionally, this situation places even greater pressure on General Practice, with patients unable to receive operations or further treatment understandably seeking support from already overstretched GPs to manage their conditions in the meantime. In turn, this has a knock-on impact on the number of GP appointments available to patients seeking initial support, diagnosis, or referral – further compounding both the number of ‘missing patients’ and the wider backlog.

3.8   Furthermore, GPs frequently have to explain to patients about delays to their care, or their position on waiting lists. This not only risks harming doctor-patient relationships but can, particularly given the wider climate of media attacks on GPs, also heighten the abuse (both verbal and physical) GPs and practice staff face.

3.9   The Health Foundation estimates that there are around 8 million missing patients.[26] They estimate that the waiting list could grow to 10–13 million if most missing patients (50 – 90%) do return and activity returns to pre-pandemic levels. The IFS also conclude that the waiting list growing to 13 million is likely if NHS capacity remains below 95% and at least two thirds of missing patients return.[27]

4. What needs to be done to address the backlog?

4.1   Urgent and comprehensive action must be taken to support doctors and NHS staff through this winter to help ease demand on services to work through the backlog. This is in the interest of patient safety, staff wellbeing, and protecting the health service’s recovery of elective care.

4.2   This is particularly important as, despite increases in recent months, the number of elective procedures taking place remains well below pre-pandemic levels, meaning that the backlog continues to grow.

4.3   It is vital to maintain infection control measures alongside promoting vaccine uptake to reduce transmission of the virus, protect the health of the public and ensure the NHS is not overwhelmed. Whilst we are encouraged that the booster programme has picked up speed in recent weeks, there remain concerns that cases and admissions to hospital are at persistently high levels. Relying on vaccination alone over winter is likely to be insufficient to prevent health and public health services from being overwhelmed by any future spike in cases. An approach which combines vaccination with other measures should be taken, such as improved support for those needing to self-isolate, education on the continued risk of Covid-19 and improving ventilation wherever possible.

Cut red tape and reduce the unnecessary workload burden

4.4   It is essential that doctors and all frontline and clinical staff can devote their time, energy, and talent to the delivery of care this winter – they cannot and must not be expected to participate in non-essential or back-office programmes.

4.5   Health services need to concentrate as much of their energy and resources on frontline care as they possibly can. Any non-essential initiatives or programmes should be paused or scrapped this winter to avoid wasting vital clinical time on unnecessary administrative reform. Similarly, the promise of any additional funding to better manage demand cannot be contingent on implementation of burdensome measures with no short-term impact.

4.6   Steps should be taken to employ dedicated staff on a seasonal basis to take on administrative duties to avoid doctors and clinical staff being diverted away from direct patient care.

4.7   All unnecessary mandatory checks and training, must be paused, maintaining only those strictly and demonstrably necessary for ensuring safe patient care. In addition, the burden of appraisal and revalidation which can take a significant amount of time away from providing direct patient care should be minimised.

End punitive pensions taxation rules

4.8   Growing numbers of doctors are considering leaving the profession or reducing their hours of work, often towards the end of their careers. BMA surveys indicate that two-thirds of UK doctors over 55, and one in eight aged between 35 and 54 are considering retiring within three years.[28]

4.9   Existing tax and pensions rules – including the annual and lifetime allowance – have been a major factor in doctors choosing to either retire early or to reduce the number of hours they work.[29] A recent survey by the Royal College of Physicians found 27% of consultants were planning to retire within the next 3 years with 42% of those planning to retire in the next 18 months.[30] Previous surveys have indicated that 86% of those planning to retire early cite pensions as one of the reasons for their decisions.[31]

4.10                 A tax unregistered scheme, as introduced within the judiciary in response to similar issues with recruitment and retention, is needed within the NHS to ensure that doctors can work as many hours as possible this winter, without facing major financial disincentives.

4.11                 As an urgent mitigation, employers need to offer the option for doctors and other higher earners within the NHS to be paid the full value of the employer pension contributions if they are left with little option but to opt out of the scheme because of pension taxation system. Such ‘recycling’ of employer’s pension contributions is commonplace in the private sector and is cost neutral to the employer.

Direct resources to where they are needed most

4.12                 Welcome additional funding has been announced to help the NHS through winter and to assist in the recovery of elective services.

4.13                 In England, specific funding to tackle the elective backlog amounts to £2 billion this year[32], and a further £8 billion over the spending review 2021 period of 2022/23 to 2024/25.[33] This is supplemented by £5.9 billion capital investment for the NHS from 2022/23, which will help invest in new technology, but cannot be used to pay for the staff time needed to ensure the backlog is reduced.

4.14                 Several other organisations have estimated the cost of clearing the backlog, with estimates ranging from £16.8 billion between 2021/22 and 2024/25 (Health Foundation)[34] to £7.5 billion (IFS).[35] The estimated funding needed depends both on the size of the backlog as discussed above, but also on assumptions around how quickly the backlog is cleared, and what waiting list times to target.

4.15                 The Health Foundation has considered two different scenarios. First, fast recovery and second slower recovery, differing in terms of targets, costing between £16.8 billion and £14.6 billion in real terms to clear the backlog by 2024/25 and 2028/29 respectively.[36] Given these estimates, the funding announced by the government is up to £7 billion short.

4.16                 The IFS estimates that clearing the backlog will cost approximately £7.5 billion over three years (2022/23 – 2024/25). This estimate is lower than Health Foundation estimates in part because they make lower assumptions about the number of ‘missing patients’ returning, as well as lower estimates of the increased cost pressures to the NHS.[37] Given the huge pressure the NHS is under, and the lack of available workforce which will likely lead to heavy reliance on costly locums, the BMA believes the Health Foundation’s estimates to be more realistic.

4.17                 However, broad announcements of new money will mean very little unless funding both reaches and has an impact on the frontline. A significant proportion of any winter funding must also be allocated to supporting the workforce through the coming months. Money targeted at expanding bed numbers or diagnostic capacity, for example, will only be meaningful if there is sufficient workforce to staff them safely.

4.18                 Prioritise workforce in all winter funding decisions: £2bn has been allocated to clear the backlog of care this financial year, but it is vital that money is also used to support the wellbeing of the NHS workforce and help retain staff. While expansion of the workforce remains a key medium and long-term priority, it is impossible to recruit or train enough doctors to help the NHS through this winter – therefore every effort must be made to keep those we have.

4.19                 Make capital funding available for all urgent repairs to hospital estates and GP premises: so that patients and staff can safely use them, resources must be made available to ensure rapid repairs and remedial works can be undertaken across the NHS estate. The maintenance backlog across the NHS remains enormous and now sits at a total of £9.2 billion in England alone, a 2.2 percent increase on the previous year[38] – as this grows, so does the risk to those who use and work in them.

4.20                 Adequately support social care: all UK governments must ensure social care is properly supported financially, to ensure it is able provide safe care to those who need it, while also helping to reduce pressure on hospital and GP services, as well as ensure timely discharge from hospital. The government have allocated an extra £5.4bn for social care, over the next three years[39]. However, the Health Foundation’s REAL Centre projects that it would need to spend between an extra £6bn in 2024/25 compared to a 2019/20 baseline (just to meet future demand) and £9.3bn (to also improve access to care and pay more for care). The recent funding announcement covers only some of this, providing around £1.5bn a year.[40]

December 2021