NHS waiting lists | The real political crisis

NHS England this week published their plan to reduce NHS waiting lists. The Elective Recovery Plan was due to be published in December, but there is a waiting list for plans about waiting lists.

There are currently 5.7m waiting for treatment on the NHS in England. That is 10.5% of the country or roughly the population of Denmark. By any standards this is a massive problem.

The waiting list will hit at least 13m, and depending on the success of the plan could rise to 19-20m. By the next General Election in 2023 a quarter of the population of England could be on the list.

The Government’s headline commitments are:

• Cut waiting lists to under a year by 2025

• Eliminate waits of over 18 months by April 2023 and over 65 weeks by March 2024.

• Restore diagnostics within six weeks to pre-pandemic levels by 2025

• Creation of list of reservist health workers to “increase capacity”

• Plan to “improve the information and support for patients” with new online platform called My Planned Care

The Government also announced 2 new Cancer waiting targets:

  • 75% of suspected cancer patients will be told if they have the disease or not within 28 days of being urgently referred by a GP 
  • 75% of people who develop cancer will be diagnosed early by 2028 

You can pretty much discard these last 2 targets as they aren’t new and have been part of the NHS performance framework for yours, they just haven’t been achieved.

A lot of the waiting list problems are the impact of Covid, but it is worth reminding ourselves that these problems were here before Covid:

The 18 week wait target hasn’t been hit for 6 years.

The Cancer waiting times target hasn’t been hit for 7 years

The A&E 4 hour wait target hasn’t been achieved for a decade

Even if the Covid backlog was dealt with the NHS still wouldn’t be performing as well as it was in 2010 when Labour left office.

Sir Jim Mackey, my old boss, has led the plan and there are a lot of innovative ideas that his organisation, Northumbria Healthcare, have been doing for a long time:

  1. Reduce the number of follow up appointments to give clinicians more time to operate and treat
  2. Allow patients to switch their appointment to a Trust out of their local area which has shorter waiting times
  3. Increase the number of Trusts operating hot and cold sites.

Of these the first 2 are helpful but I am not sure how much of an impact they will have. Shopping around for a Trust with a shorter waiting list doesn’t really work if there are 6m others doing the same.

Splitting Trusts into hot and cold sites, is a very good idea, but controversial. Northumbria, and a few other Trusts around the UK operate a “hot” and “cold” model. They have a number of different hospitals sites but only one of them offers A&E services – the “hot” hospital. All the rest only offer elective/planned “cold” care. This has the massive advantage because it means that the Trust can maintain it’s planned elective workload even if there is a big spike in emergency admissions. I am a big fan of this model.

It does however have some massive political problems.

Switching to hot and cold working means closing A&E departments in order to create cold sites. This is politically explosive. Right now red wall Tories are fighting (at least in public) to re-open A&E departments not shut new ones. Even with a big majority Boris doesn’t have the political capital or the time to do this work before 2024. It is simply not an option.

Working for the NHS and DH there were some pretty strict rules in the Blair era about doing difficult things. Anything complex or controversial had to be done within the first 2 years of a Government. Once you were within 24 months of a GE it was too politically difficult to get anything done. Addressing waiting list problems mean changes to services but we are too close to a GE, and the Government lacks the political capital to make it work.

Health service reforms also need an incredible amount of focus and effort. The current Government has neither of those things. It is driven by headlines, and jumps from policy to policy depending on the news cycle. Ministers consistently underestimate how difficult things are, and then when they hit problems they give up and move on to something else, in the manner of a management trainee in their first corporate job. Alongside trying to rescue NHS performance the Government is planning to reorganise the NHS completely, scrapping the internal market and extending Department of Health control over the NHS. The centralisation of control will do nothing to improve patient care- DH are notoriously bad at management which is why everything they did during the pandemic was a shambles from PPE to track and trace. Instead it is about messaging – keeping Doctors and managers on message, and stopping the public hearing stories about lack of staff, poor quality care or lack of funds.

The current long waiting lists represent a huge amount of pain and suffering but also a politically explosive situation. The next General Election is in 2024 at the latest. Improvements in waiting lists will be small if at all. The Government will be fighting a GE with up to 20% of the population of England waiting for treatment, a higher proportion among over 65s; the Government’s key client group. We don’t know how bad things are going to get because we know that there were 5m fewer referrals to secondary care during the pandemic, and these patients will turn up eventually, probably sicker and in need of more complex treatment.

This is despite huge rises in tax and NI to fund the NHS and social care – people will want to see this funding generating meaasureable improvements long before then.

Thatcher’s spell as Prime Minister was defined by 3m unemployed. Boris, and whoever comes after him will find that 20m on the waiting list is their defining number.

https://www.kingsfund.org.uk/blog/2021/11/nhs-waiting-lists-how-big

https://ifs.org.uk/publications/15557

https://www.england.nhs.uk/coronavirus/publication/delivery-plan-for-tackling-the-covid-19-backlog-of-elective-care/

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