Conference Report

Despite COVID-19, commitments to invest in the NHS must be honoured

| By Alastair Whitington

Alastair Whitington summarises highlights from the Westminster Health Forum conference on the future of NHS funding

About the Author

Alastair Whitington

Consultant Editor for Specialised Medicine; Trustee for Neuroblastoma UK.

Alastair led NHS England specialised commissioning engagement with providers and eight CCGs in North West London from 2013–2015. He was also Programme of Care Lead for London, responsible for the design and development of the commissioning framework and delivery of national strategies for over 100 specialised services. Alastair previously managed the Cancer Drugs Fund and Individual Funding Request process for specialised services in London.

The Westminster Health Forum, Key decisions for utilising NHS funding—priority areas, quality and delivery of care, the COVID-19 crisis, and long-term financial stability, was held online on 24 September 2020.

Danny Mortimer, Interim Chief Executive, NHS Confederation, reported that the NHS Confederation initiated a programme called NHS Reset over the summer, which draws upon the reflections of its members, consisting of providers and commissioners across health and social care, on their experiences of the pandemic. The campaign aims to recognise the successes of the response to COVID-19 and ensure that all progress made is incorporated into plans for the health and care system of the future.1

Mr Mortimer said that the preceding 6 months had been a significant challenge, and that health and social care teams have shown enormous dedication, expertise, and resilience in meeting the demands of COVID-19 in a system already working at its limits. However, dealing with the initial surge resulted in the suspension of elective work and, moving forward, the consequent backlog will need to be addressed, as will the ongoing needs of those who contracted COVID-19.

Although dealing with the pandemic reinforced and accelerated collaborative working, Mr Mortimer felt that the scope for such collaboration had been limited by the failure of successive governments to provide a proper long-term plan and investment for the social care sector. However, leaner and lighter regulation in response to the pandemic had been of benefit over the preceding 6 months. The stepping back of the Care Quality Commission,2 and the different approach to regulation adopted by NHS England,3 aided innovation and hastened the introduction of changes without the usual bureaucracy.4

Mr Mortimer stated that the pandemic has reminded us that the NHS is ‘made of people’, and that the successes of the response to COVID-19 are due to the efforts of teams across the NHS, who have been very adaptable and flexible in both responding to the pandemic and reinstating non-COVID-19 work. In addition, Mr Mortimer said that the pandemic has highlighted the importance of the wellbeing of people who work in the NHS, and that it was the problem of high numbers of vacancies within the workforce that necessitated prioritisation of work on coronavirus-related activities in the first wave. These underlying workforce problems remain, and also serve as a reminder that every NHS organisation provides a poorer and more discriminatory experience to its black and minority ethnic staff.

The pandemic did trigger some positive developments. Mr Mortimer indicated that, over the preceding 6 months, greater importance had been attached to the uptake of technology, how healthcare facilities are used, the impact of delays to treatment, and our understanding of inequalities in how people access healthcare. New technology has now changed the way in which healthcare professionals interface with patients, but it has also offered patients greater control over their access to health services.

However, Mr Mortimer stated that, although the NHS benefits from having a long-term plan and associated financial commitments, additional funding requirements have arisen due to operational costs related to the response to COVID-19, ongoing capacity constraints imposed by infection control measures, the need to build greater resilience across the healthcare system, and additional demand on mental health and rehabilitation services post-COVID-19.

In addition, Mr Mortimer reported that, although there were existing pressures prior to COVID-19 and the NHS was struggling to meet performance targets, the pandemic has significantly increased the backlog of work and waiting times. In March 2020, over 46,000 patients had been waiting 6 weeks or more for one of 15 key diagnostic tests;5 in November 2020, this figure had risen to nearly half a million patients.6 The associated delays in treatment and unmet demand may mean that patients’ symptoms are now more severe.

Mr Mortimer asserted that it will be necessary to invest in the wellbeing and support of staff through these challenging times, and that there is a need to support growth in undergraduate education and apprenticeships. There will also be pressure to reward staff financially for their commitment, and this will require additional funding from the Government.

Finally, Mr Mortimer stressed the need for a plan for and investment in social care in its own right, not only to support the release of NHS capacity, but also to improve out-of-hospital care, boost the pay of care workers, and invest in training and development. The Government’s commitment to invest in capital and infrastructure to improve the quality of care and working environment within the NHS must be honoured.

Professor Tim Briggs, Chair, Getting it Right First Time (GIRFT) and National Director of Clinical Improvement, NHS England and NHS Improvement, advised that the GIRFT programme was about increasing productivity, squeezing out unwarranted variation, and delivering high-quality care to patients. The programme has 46 specialty workstreams and will have produced 38 national reports by July 2021.7,8

Professor Briggs illustrated the improvements made by the GIRFT programme using the example of orthopaedics, in which GIRFT data were used to achieve reductions in length of stay (LoS), inappropriate arthroscopy rates, and revision rates, and a year-on-year reduction in litigation claims from 10% of total NHS claims to 4%.9 It is anticipated that claims will also decrease in other specialties as the programme is implemented and service quality improves.

Furthermore, Professor Briggs highlighted the work undertaken to reorganise services in Lincolnshire to make Grantham the elective site for orthopaedics. The separation of elective and emergency work between hospital sites and the application of GIRFT methodology led to Lincolnshire becoming an exemplar in LoS for hip and knee replacement, with increased day case rates and significantly improved outcomes.10 However, not all services are responsive to GIRFT data; despite repeated visits, one London hospital still has a long LoS, high readmission rates at 30 days post-surgery, high revision rates, and poor outcomes.

Professor Briggs reported that the COVID-19 pandemic had led to a significant reduction in elective surgery across all regions, irrespective of the number of patients with COVID-19 admitted, with London profoundly affected.11 The result is that, in July 2020, over 83,000 patients had been waiting 52 weeks or more for elective surgeries across all specialties;12 4 million of these patients are on the surgical waiting list, with potentially more patients yet to be added to the waiting list because of under-referral during the pandemic.13 As trusts have been struggling to resume work at previous levels, Professor Briggs believed that simply returning to usual will not address the problem and that something transformational is required.

In London, to address this problem, Sir David Sloman, NHS London’s Regional Director, decided to use GIRFT expertise to transform London’s healthcare, initially in high-volume low-complexity (HVLC) surgery. Professor Briggs said that the aim in London was to get rid of ‘average’, with a drive to make the top decile the new normal. To reduce variation, all stakeholders across all providers in London signed up to the creation of standardised, procedure-level clinical pathways. The new pathways were developed by expert advisory panels supported by the professional societies and Medical Royal Colleges, and included productivity expectations on the number of procedures undertaken on each surgical list. Professor Briggs said that ‘in just 6 weeks, 29 pathways across six HVLC specialties were standardised, covering 60% of patients waiting over 52 weeks in London’. Furthermore, each of the five integrated care systems (ICSs) in London will be benchmarked against top-decile performance by the end of January 2021. The organisational level of ICS was chosen based on equity of access and excellent clinical outcomes for the population through the standardisation of pathways and adoption of best practice.

To illustrate the opportunity for London in orthopaedics, Professor Briggs stated that if all ICSs achieved the top decile in all performance measures, ‘it would free up 83 beds and deliver over 7000 additional primary hip and knee replacements, with a potential reduction in litigation costs of £67 million over 5 years’. One area for improvement around the country is treatment for femoral neck fracture: Professor Briggs said that ‘if all services in London achieved top-decile performance for this procedure, it would free up 104 beds, enabling 16000 more surgical procedures to be undertaken within the existing bed base’.

In ophthalmology, there are similar potential benefits. If the day case rate achieved top-decile performance, with a theatre flow of 10 cataract operations per half-day and a cataract conversion rate of 95% from the first outpatient visit, ‘an additional 4000 cataract operations could be delivered within the existing capacity, with an estimated saving of £10 million over 5 years in litigation costs’.

Professor Briggs advised that the GIRFT programme is being extended between September and November 2020 to cover four other HVLC specialties (gynaecology, general surgery, ear, nose, and throat surgery, and urology). In London, the elective activity for these specialties will focus on COVID-19-free ‘hub’ sites that will deliver HVLC work, resilient to winter/COVID-19 pressures, giving patients confidence that they can have their surgery in a safe environment.

In addition, Professor Briggs reported that the development of a model health system utilising Secondary Uses Service data14 has provided an interactive, ‘live’ tool to monitor the 42 ICSs in England and support conversations to understand variation and drive changes in practice. GIRFT has also developed a National Day Surgery Delivery Pack to support the delivery of safe and efficient day surgery,15 with the expectation that ‘80% of elective surgery will be performed as day surgery’.

With respect to operating theatres, Professor Briggs cited a report published in February 2019 that analysed a year’s data from 92 trusts on variations in productivity (such as late starts, early finishes, and turnaround time between cases).16 The report indicated that, if all services moved to the top decile, an extra 291,000 routine operations could be undertaken within the same capacity.16 Theatre principles have now been established to maximise efficiency and productivity, including theatre list planning, guidance on cases per list, start and finish time, and turnaround time between cases.

In conclusion, Professor Briggs indicated that national recovery in waiting times will require clinical transformation—using GIRFT methodology to create standardised pathways and theatre principles backed up with robust, real-time data—and that there can be no return to pre-COVID-19 behaviour.

This conference report was prepared by Specialised Medicine and the speakers have not had the opportunity to make corrections.

References

  1. NHS Confederation. NHS Reset. nhsconfed.org/NHSreset (accessed 14 December 2020).
  2. Care Quality Commission. Joint statement on our regulatory approach during the coronavirus pandemic. cqc.org.uk/news/stories/joint-statement-our-regulatory-approach-during-coronavirus-pandemic (accessed 14 December 2020).
  3. NHS England and NHS Improvement. Next steps on NHS response to COVID-19. London: NHS England and NHS Improvement, 2020. Available at: england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf
  4. Busting bureaucracy: empowering frontline staff by reducing excess bureaucracy in the health and care system in England. www.gov.uk/government/consultations/reducing-bureaucracy-in-the-health-and-social-care-system-call-for-evidence/outcome/busting-bureaucracy-empowering-frontline-staff-by-reducing-excess-bureaucracy-in-the-health-and-care-system-in-england (accessed 14 December 2020).
  5. NHS England. Monthly diagnostics data 2019-20. London: NHS England, 2020. Available at: england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2019-20/
  6. NHS England. Monthly diagnostics data 2020-21. London: NHS England, 2020. Available at: england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/monthly-diagnostics-data-2020-21/
  7. Getting It Right First Time. www.gettingitrightfirsttime.co.uk/workstreams/ (accessed 14 December 2020).
  8. Getting It Right First Time. www.gettingitrightfirsttime.co.uk/girft-reports/ (accessed 14 December 2020).
  9. Getting It Right First Time. Feature shows how GIRFT has influenced fall in litigation claims for orthopaedic surgery. gettingitrightfirsttime.co.uk/feature-shows-how-girft-has-influenced-fall-in-litigation-claims-for-orthopaedic-surgery/ (accessed 14 December 2020).
  10. United Lincolnshire Hospitals NHS Trust. A ‘united’ approach to orthopaedics. ulh.nhs.uk/news/orthopaedic-trial/ (accessed 14 December 2020).
  11. Gardner T, Fraser C, Peytrignet S. Elective care in England—assessing the impact of COVID-19 and where next. London: The Health Foundation, 2020. Available at: health.org.uk/sites/default/files/2020-11/Elective%20care%20in%20England.pdf
  12. NHS England. Consultant-led referral to waiting times data 2020-21. London: NHS England, 2020. Available at: england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2020-21/
  13. Donnelly L. Patients face being sent to back of NHS queue as waiting list reviewed. telegraph.co.uk/news/2020/10/04/everypatient-nhs-hospital-waiting-lists-reassessed-lockdown/ (accessed 14 December 2020).
  14. NHS Digital. Secondary Uses Service (SUS). nhs.uk/services/secondary-uses-service-sus (accessed 14 December 2020).
  15. Best practice library—day surgery. London: GIRFT, 2020. Available at: www.gettingitrightfirsttime.co.uk/best-practice-library-day-surgery/
  16. NHS Improvement. Operating theatres: opportunities to reduce waiting lists. London: NHS Improvement, 2019. Available at: nhs.uk/resources/operating-theatres-opportunities-reduce-waiting-lists/