NHS0043

Written evidence submitted by NHS Providers

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. NHS Providers has all trusts in voluntary membership, collectively accounting for £92bn of annual expenditure and employing more than one million staff.

Key messages:

• Before the pandemic, despite the NHS treating record numbers of patients[1], demand was outstripping capacity, placing pressure on performance standards, with a number of trusts recording their lowest results to date. This was in part due to increased demand, austerity funding, reduction in bed capacity, workforce shortages and a lack of capacity in social care.
• The NHS therefore entered the pandemic under severe pressures and is now facing a significant backlog of care across a range of services, including urgent and emergency care pathways, planned operations, mental health and community services, exacerbated by COVID-19. Trusts and frontline staff are working incredibly hard to bear down on this backlog, but there is ongoing uncertainty over how many people will continue to come forward in need of care, the number of hospital admissions due to COVID-19 hospitalisations in the future, and how quickly we can stabilise the urgent and emergency care pathway. All of these factors could have a significant impact on how quickly the NHS will be able to reduce waiting lists.
• The waiting list for elective care continues to grow. In October 2021, the elective care waiting list was 5.98 million, and treatment activity has remained below normal levels. NHS cancer services activity has recovered to pre pandemic levels. However, in September 2021 only 68% of patients requiring treatment within 62 days of urgent referral by their GP were receiving that treatment on time[2].
• Support to recover performance should include a fully funded long term workforce plan, further improvements to the NHS’s culture and ways of working, temporary and permanent capacity expansion, an increase in capital funding and investment in digital technology and transformation.
• Trust leaders have welcomed the government’s support during the pandemic and the recent three-year revenue settlement. But even with this extra funding, we must be honest with the public about the scale of the challenge ahead, and the length of time it will take for the NHS to address the backlog across services.
• The pandemic exacerbated the challenges facing both the NHS and social care pre-pandemic.  Despite recent announcements and the health and care levy, the social care system is still in need of reform to ensure its sustainability and expand access for those with unmet needs. We must therefore learn from the experience of the pandemic and be better prepared for future events. The underlying causes which led to the current unsustainable pressures the NHS and care system is facing must now be addressed.

Before the pandemic, what were the root causes of the NHS’s deteriorating performance against the standards required for waiting times for elective care and cancer services?

1. Demand for healthcare has been consistently increasing over time. As outlined in the National Audit Office’s (NAO) report on NHS backlogs and waiting times in England[3], before the COVID-19 pandemic, despite the NHS doing more work year-on year and treating record numbers of patients, demand for services was increasing at a faster rate and trusts were recording their lowest results against national performance standards[4]. The overriding issue affecting performance is the mismatch between demand and capacity across health and care. With trusts recording their lowest results against national performance standards in elective surgery and emergency care in over a decade, this deteriorating performance was due to increased demand, austerity funding, reduction in bed capacity, workforce shortages and the need for more capacity in social care.
2. In order to improve performance standards, efforts must now be focused on transforming service delivery to match population needs. Our population is aging, demand for health and social care services is increasing, and innovative technology is creating opportunities for better, more personalised care and support. For the NHS to continue developing its care and services to meet changing needs, it needs the government to deliver an effective long-term workforce strategy for health and care; focus on creating a workplace culture that makes the NHS a great place to work; invest in digital technology and transformation; and develop new initiatives to support the adoption of new medicines and other technologies.

What did the NHS do well and what could it have done better in providing elective care and cancer services during the pandemic?

3. Colleagues across the NHS acted swiftly and successfully in response to the changing demands of the pandemic.  As outlined in our submission for the Health and Social Care Committee inquiry on clearing the care backlog, the pandemic acted as a catalyst for change, in particular by enabling greater collaboration across the system to find better ways of working. This resulted in significant achievements such as the added availability of 33,000 beds early on in the pandemic. The NHS is now accelerating whole system working, both ‘horizontally’ at ICS level bringing together acute services, or community and primary care services, across a larger geographic footprint, and ‘vertically’ in place-based partnerships across community services, mental health, primary care and local acute services, as well as other partners such as local authorities and the voluntary sector. System working and the emerging local provider collaborative structures are and will continue to be helpful vehicles to tackle backlogs of care and waiting times.
4. In a survey[5] of NHS trusts carried out in July 2021, respondents noted that elective care was one of the services for which activity was increased to meet demand, specifically through prioritising according to clinical need, additional temporary theatre capacity, extra lists, and regular reviewing of waiting lists. Inpatient elective care activity increased in September 2021 from the previous month, with the number of admitted inpatient pathways increasing by 8.9%, meaning that a total of 252,699 inpatient treatments were carried out. Non admitted pathways also increased, with the NHS delivering 1,038,803 elective non-admitted pathways – an increase of 14.8% on the previous month. There was also an increase in cancer activity, with more people being seen within two weeks of an urgent referral, and more people completing both the 31- and 62-day pathways[6].
5. Collaboration between primary and secondary care was bolstered during the pandemic. Here, we saw new approaches embraced, improved communications and shared information across organisations, and the adoption of digital transformation and new technologies. For example, at one trust GPs are able to request advice from consultants and send images relating to the request, which then enables consultants to make decisions, potentially avoiding the need for an initial outpatient consultation and thereby speeding up the patient journey. As providers across primary and secondary care increasingly work together in a range of new collaborative arrangements, new partnerships will be required to sustain and accelerate the drive to reduce the care backlog generated during the most disruptive days of the pandemic.
6. The pandemic exacerbated the challenges the NHS and social care were facing pre-pandemic so, we must learn from what happened and be better prepared for any future events. The underlying causes which led to the current unsustainable pressures the NHS are facing must be addressed, including addressing the broken workforce model, the insufficient capacity to match growing demand, and a social care system facing urgent pressures. While the recent government funding commitments are welcome, the lack of detail on future education and training, social care and public health budgets is a significant concern for trust leaders, and it is therefore unclear as to whether the government’s financial plans will go far enough to support health and social care services.

What are the biggest challenges faced by local healthcare providers in recovering performance on waiting times for elective care and cancer services? 

7. The waiting list for elective care continues to grow, with referrals continuing to outstrip activity. In October 2021, the elective care waiting list was 5.98 million, reaching a new all-time record, and is now 34% greater than two years ago before the pandemic[7]. While trusts are working hard to clear the backlog of care that built up during the pandemic, trust leaders are reporting that their organisations are facing the toughest pressures they have ever known.[8], 84% of trust leaders were very worried (35%) or worried (49%) about their trusts having the capacity to meet demand for services, in part due to staff capacity and the chronic staff shortages prevalent before the pandemic, but also due to continuing loss of capacity as a result of the NHS having to redirect many resources, such as beds, away from its normal activities. The two trust leaders from the ten ambulance trusts (100%) who responded to the survey were very worried about their trusts’ capacity to meet demand for services. All (100%) trust leaders from mental health and learning disability trusts were very worried (47%) or worried (53%).

8. The most recent NHS performance and activity data[9] highlighted that cancer services activity decreased this month for the two-week pathway (-1.7%), 31-day pathway (-6.6%) and 62-day pathway (-7.9%). Further still, performance on the two week and 62-day pathway continues to deteriorate and the NHS is still missing all key national targets. Ambulance category 1 incidents continued to rise and reached the highest levels since records began, and the ambulance service has missed the average response time target of seven minutes for category 1 calls for the sixth consecutive month. Performance for A&E and emergency care against national targets has continued to deteriorate, with the service registering the worst performance on record. NHS staff continue to go above and beyond to deliver care, but with 94% of hospital beds occupied[10], the NHS is running beyond capacity and there is very little flex in the system.

9. Staff availability to meet this increased demand is the biggest challenge healthcare providers are facing. Recent NHS Digital vacancy data[11] shows that the total number of vacancies is continuing to increase - there are now 99,460 vacancies, which is an increase of 14% compared to this time last year. Moreover, the NHS workforce is exhausted and overstretched. NHS staff continue to go above and beyond to deliver healthcare, but almost all[12] (94%) trust leaders have highlighted that they are extremely or moderately concerned about the current level of burnout across their workforce. This is coupled with chronic staff shortages that were prevalent before the pandemic.

10. Although the advice on social distancing in clinical settings has recently been updated, trusts are also facing a continuing loss of capacity as a result of the need to protect patients, service users and staff from nosocomial infection. The NAO’s most recent report[13] highlighted that during the pandemic, staff and beds have had to be reserved for COVID-19 patients and many empty beds could not be used due to the need to hold capacity in reserve, or for infection control measures. For example, trusts have had to create separate areas: red for COVID-19 patients, amber for patients waiting for test results, and green for non-COVID-19 patients, which has reduced capacity by up to 20% while the continued need for infection prevention and control measures has slowed or disrupted planned surgery[14]. This has led to an increase in the number of patients waiting more than 18 weeks for elective care by 5.6%, meaning that performance against the 18 weeks standard worsened, falling by 1.1% to 66.5%[15].

11. Trust leaders across all types also not only reported[16] increases in demand, but also that people being referred for care have more complex needs and higher levels of acuity. It is also such that later stages of cancer are being diagnosed due to delays in gaining treatment and a backlog of diagnostics. The human impact of these pressures is a huge concern for trust leaders.

12. While the multi-year capital settlement announced in the spending review is welcome, after years of underinvestment and capital budgets being diverted at a national level into revenue, too many providers are struggling with inadequate buildings, failing equipment and an inability to adopt new technologies for patient care or provide a modern working environment for staff. COVID-19 has exposed the challenges created by an outdated estate, such as difficultly expanding capacity at pace to adhere with strict IPC measures. These issues will only be rectified with a properly funded and well-designed system of capital funding. Trusts have expressed the concern that current national support for trusts to tackle the backlog of care and recover performance on waiting times is not sufficient[17]. An increase in capital funding would allow for the expansion of wards and service capacity, reducing waiting lists and improving pathways.

13. Further changes are also needed to the NHS’s culture and ways of working. Staff are the bedrock of the NHS. Rapid solutions to a range of workforce issues – such as training, pension taxes and staff pay, terms and conditions – are therefore vital. Greater flexibility and appealing career pathways are also needed, along with policies that support the NHS in building a committed workforce and increasing supply. It is hoped the forthcoming elective recovery plan will go some way to progressing this.

How should DHSC and NHSE support local providers to recover their performance? 

14. Retention of NHS staff is central to tackling the backlog of care and there needs to be a fully funded long term workforce plan. The recruitment of new staff is also essential to support trusts’ recovery plans. The wellbeing of the NHS workforce must also be protected to further ensure that there are enough staff to fill workforce gaps, and flexibility must be built into the system, allowing staff to manage the backlog effectively.

15. Further support to recover performance should include temporary and permanent capacity expansion, funding for the use of and implementation of innovative approaches to tackle the backlog, and a target recovery trajectory in terms of speed of recovery.

16. One initiative we have suggested is that government funds a retention payment for social care workers over the immediate, pressured winter months. Investing in social care appropriately will help support people to remain independent in their own homes and enable them to return home once medically fit after a period in hospital.  Latest figures suggest one in ten patients is delayed in hospital due to a lack of available care at home and in the community[18]. Dedicated funding for discharge to assess also remains essential (and, as it stands, will run out at the end of this financial year).

17. In anticipation of the publication of an elective recovery strategy, the strategy will need to address the following to support local providers to recover performance:

1. Recognition of the extraordinary pressures trusts are facing, including on the urgent and emergency care pathway

2. A focus on how trusts can address health inequalities as they seek to reduce waiting times.  Much of this work is already underway

3. A system-wide view of the care backlog across acute, mental health, community and ambulance services to ensure that the wider system is equipped to meet the challenges presented by the backlog.

4. Careful communication between politicians and the public so there is a shared understanding of what is realistically achievable over the next three years.

Are plans and funding announced to date enough to help the system recover or, if not, what in your view is still missing? 

18. Trust leaders have welcomed the government’s support during the pandemic and the recent three-year revenue settlement. But even with this extra funding, we must be honest with the public about the scale of the challenge ahead, and the length of time it will take for the NHS to address the backlog across services.

19. The combined funds raised via the levy and the other adjustments made by the treasury are welcome, however, the additional £9.0bn announced for 2022/23 still falls short and leaves trusts facing difficult choices about how to prioritise care for patients. NHS Providers and the NHS Confederation estimate the NHS needs an additional £10bn in 2022/23 to cover ongoing COVID-19 costs, address the care backlog (across all sectors) and make appropriate allowance for lost efficiency savings[19]. The government will also need to keep the funding available to the NHS under review, given the ongoing uncertainties presented by the pandemic.

20. We welcome the fact that DHSC has been set a multi-year capital budget, including £5.9bn over the next three years to support elective recovery and improve digital technology. However, the many demands on the capital budget means funds will be stretched. Further still, it is unclear how much money will be allocated to integrated care systems in 2022/23 and beyond to tackle the growing maintenance backlog, which now stands at £9.2bn. Sufficient capital funding would allow trusts to reduce their maintenance backlog, improve their estate (modernise, improve efficiency, and reduce their carbon footprint) and invest in digital infrastructure. For the system to recover, it is vital there is an increase in capital funding as this would ultimately allow for the expansion of wards and service capacity, reduce waiting lists and improve pathways.

21. It is also vital that the system for accessing and allocating capital is reformed in consultation with those planning and delivering services. Funds must reach trusts quickly and be distributed according to the principle of subsidiarity if the NHS is to make the most of every pound.

22. The health service urgently needs a robust, long-term workforce plan, as well as increased investment in workforce expansion, education and training. Staff shortages and unsustainably high workloads are the NHS' biggest challenges.
23. Unless the number of patients being discharged is smaller than the number of new patients being referred, trusts’ waiting time performance will deteriorate. We would therefore welcome clarity on dedicated funding for the discharge to assess model, as this is crucial to continue recovering care backlogs at maximum speed. 

24. NHS and social care services work closely together to deliver for patients. While the spending review confirmed some additional resources for local government, there was little information on the government's future plans for social care and public health. Social care staff have worked incredibly hard throughout the pandemic, and their vital work to keep people well and independent in the community is essential not only for individuals but also for the effective functioning of the health and care system. The government must deliver on its commitment to place vital social care services onto a sustainable financial footing, so people receive the right care in the right setting.

December 2021