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Can the NHS clear its backlog?

More than six million people are now waiting for health service treatment in England.

By Harry Clarke-Ezzidio

Currently, over seven million people across England, Wales, Scotland and Northern Ireland are waiting to receive treatment on the NHS. Elective procedures and screenings, as well as treatments for cancer, heart disease and other ailments, continue to pile up.

The health service is clogged in every home nation. With 700,000 electives to be done in Wales, the Welsh Conservative Russell George said that Labour needs to “stop breaking all the wrong records”; Humza Yousaf, the SNP Health Secretary, was told by a fellow MSP to “finally show some leadership and get a grip” of Scotland’s 550,000-long waiting list; while Northern Ireland Health Minister Robin Swann has remarked that its current figure of 120,097 people waiting for treatment is “simply not acceptable”.

Plans have been outlined to tackle the backlog, but some experts believe that things could get worse before they get better. 

“A lot of that depends on what’s called ‘missing referrals’ or ‘missing patients’,” Stephen Rocks, an economist at the Health Foundation charity, tells Spotlight. Such patients are those who would have otherwise accessed their GP or visited hospital for their illness if not for the pandemic, sparking fears of an as yet untreated mass of people. (The National Audit Office estimates that there were between 7.6 million and 9.1 million fewer referrals for elective care between March 2020 and September 2021.) “That remains something over which there’s a great deal of uncertainty,” Rocks adds, “and the government’s been quite open about that when setting out its elective recovery plan.”

NHS England’s recovery plan, published in February, concedes that the elective treatment waiting list, which currently stands at 6.4 million people in England, “is likely to increase, at least in the short term”. Similar blueprints for recovery in Wales, Scotland and Northern Ireland acknowledge this reality, too.

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Though funding pledges and personnel numbers differ, the plans to clear backlogs across the home nations have the same general premise: tend to the sickest first, treat those who have been waiting longest quickly, and restore the speed of the healthcare process to pre-pandemic levels.

The backlog will take years to clear. In England, which has the biggest backlog, the number of people who have waited over a year for treatment is 186 times higher than it was pre-pandemic. The average patient now spends 13.1 weeks waiting for treatment across a range of conditions.

As part of the recovery plan, NHS England has pledged to spend £8bn across the next three years, including a £5.9bn capital investment in beds, equipment and technology. It is hoped that the separation of elective care from urgent and emergency treatment, through the expansion of recently introduced localised community diagnostic centres, new dedicated surgical hubs, and the offering of treatment through independent providers – free at the point of use – will drive down numbers.

There are also plans for additional staff to join the service, though it remains unclear whether long-term need will be met. NHS England is planning to recruit 60,000 more nurses by 2025, which matches the amount that The Health Foundation predicts it will need moving forward; however, no formal plans have been outlined to recruit the 247,900 staff, including 23,900 doctors, 6,600 GPs and other support staff that the think tank predicts the health service will need to cope with demand over the next decade.

And though a record number of people work for the NHS, there is also a record number of vacancies: more than 100,000. “We don’t think current plans go far enough, nor will it see the NHS deliver enough staff to meet the needs of the population,” says Rocks.

The health service has a recent history of underfunding and understaffing. “Waiting lists were already rising prior to the pandemic,” Rocks notes. “The NHS has been facing these challenges, and especially over the 2010s," he said, referring to the years that the Conservative government implemented a policy of austerity. "We saw below historic levels of funding growth – and associated with that, we started to see waiting lists ticking up.”

The pandemic is often blamed for the backlog, but over 4.43 million people in England were on NHS waiting lists before it – a record at that time.

Staff shortages and a lack of beds, facilities and equipment are key foundational problems that could not match rising demand, argues Siva Anandaciva, chief analyst at the King’s Fund think tank. “The whole system is interrelated; there's no point in having the flat surface you call a bed in a hospital if you can't staff it - and you can't staff it unless you've got the budget.” 

Anandaciva, who previously helped draw up policy at the Department for Health, believes that since the 2008 financial crash, the NHS has fallen into a “vicious cycle”, where various “hard-fought gains” – such as meeting the four-hour A&E waiting time and the 18-week standard of referral for treatment targets – have eroded. 

“For people like me, 3,000 to 4,000 people waiting over a year for care was seen as anathema; it was seen as a massive system failure," he adds. “Now, you’ll hit 100-fold increases [of waiting lists] in some cases. You're constantly redefining what bad looks like.”

To try and deal with general demand, the NHS has strengthened its relationship with independent health providers over the past two decades. Additional beds and personnel were sub-contracted from the private sector during the pandemic. At a recent public accounts committee hearing, Amanda Pritchard, the chief executive of NHS England, said continuing relationships with the private providers will “play an extremely important part” in clearing the backlog.

Is the NHS becoming too reliable on independent providers? “I can't see any conceivable way in which you tackle the backlog without the heavy role of the private sector,” says Anandaciva. The private sector not only provides extra beds and general capacity through subcontracting, he adds, but in providing care for those who have the means to pay, it gives the NHS fewer people to treat, allowing it space to breathe.

But many skilled NHS staff also take on some work for independent providers. Such overlap, Anandaciva warns, means the service could see increased pressure on staffing numbers. "It's sharing anaesthetists, surgeons, senior consultants, nurses, allied health professionals,” he says. 

Real-terms pay cuts, limited career development, frustrations with pensions, and the pressure of operating in a stretched system has seen record numbers of staff leave the NHS: around 140,000 left between September 2020 and September 2021. “People are incredibly tired – they've been working above and beyond the call of duty for two and a half years now,” says Gary Howsam, a GP based in Peterborough and vice chair of the Royal College of General Practitioners.

The backlog also has a negative knock-on impact on other areas of healthcare: according to NHS figures, at a primary care level GPs are being asked to deal with more patients than ever before; emergency departments become easily overwhelmed with the effects of untreated patients; and a lack of capacity in social care makes it harder to discharge older patients in receipt of elective care. “You've got to be really careful that when you focus on one part of the system [that] you don't get unintended consequences elsewhere,” says Howsam.

While many agree the pledges outlined in the long-term plans will help in some form, a failure to put forward a strategy or funding to significantly boost staffing and capacity levels means that the backlog is likely to remain. “Even with a fair wind, we'd be incredibly lucky to get waiting times back to where they were before the pandemic – let alone back to where they should be,” says Anandaciva. 

NHS trusts and patients themselves can expect to see change, he adds: hospitals within the same region could soon "pool" resources to tackle patients and specific problems together, rather than act as individual entities, while patients will have greater ease of access to care with more localised treatment arrangements. 

“But unfortunately, at least for the next few years, I think a large part of the conversation will be getting better at explaining to people why they're waiting for such a long time for the care they need,” says Anandaciva.

This article was originally published on 21 June 2022.

[ See also: The NHS is under strain from Covid once again ]

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