Yesterday, NHS England released data revealing for the first time how many people have been on elective care waiting lists for more than 18 months and more than two years.
Up until now, the reporting timeframe of patient waiting lists only stretched to “longer than a year” but due to the impact of Covid-19 the reporting times have increased.
We now know that there are nearly 65,000 people who have been waiting for treatment for more than 18 months, including nearly 3,000 who have been waiting for more than 2 years. It is also the first time that the number of people on waiting lists in England has topped 5 million.
While record numbers waiting for elective surgery is most alarming and should certainly be a key element of focus for the NHS, a potentially bigger problem might be an issue which was raised in the Health Service Journal yesterday.
The article argues that the NHS’s most concerning waiting list problem right now may not be the total number of ‘long waiters’ but is instead the backlog of so-called ‘P2s’ – patients needing treatment within a month.
Many trusts are prioritising P2s. This is seen as the right clinical and moral approach, as these patients are at the most immediate risk of major deterioration and harm. Although these are the patients whose care is likely to become significantly more complex and costly while they wait, some are still waiting upwards of a year or more.
And it doesn’t seem that the issue of these urgent patients will be eliminated in the immediate future. King’s Fund chief analyst Siva Anadaciva said: “[A] worrying element of the issue [around P2s] is that some of the people I’m speaking to in the system are not expecting matters to be resolved any time soon. One figure I spoke to said they were looking at eliminating long waits for P2 patients only by the end of 2021.”
Thinking about patient flow this presents three different areas of focus in the conversation around elective care backlog – all concerning and requiring attention.
1. Addressing super-stranded patients
In April we highlighted that it will be impossible to manage any backlog without addressing super-stranded patients. At that point (from which the most recent data are available) there were over 10,000 beds in England being occupied by super stranded patients (patients who have been in hospital for over 21 days). Many of these will be complex patients or potentially out-of-area patients which require dedicated time and effort to pull in wider partners.
We know super-stranded patients are a manageable problem, but we are seeing more of these patients in acute beds rather than moving into community pathways. Dedicated hospital discharge services are able to efficiently manage rehabilitation needs, TTOs and support families in decision making – all critical ingredients in efficient discharge.
2. Partnership working
As we move through different phases of easing restrictions, we cannot forget that there is still a significant amount of work to get done before we return to pre-Covid waiting times. The NHS has been formidable in its response to Covid-19, but we must recognise that the battle is far from over. It will take a strategic and collaborative effort from organisations across the health and care sector working in tandem to get back to acceptable levels.
3. Focussed attention on complexity
Hospital discharge is the backbone of patient flow and a concerted and continuous effort must be applied to ensure that the backdoor is not a contributing factor to any delays for people being admitted. Complex admissions generally result in complex needs at discharge which we know has traditionally been a contributing factor to lack of available beds. These patients are easily identified on admission and often already have an element of care delivery which usually requires a high degree of engagement to ensure it remains in place for the patient to return to once treated. It may be residential care home bed, a domiciliary care provider or family carers. These existing provisions are often allowed to fail rather that exploring if it could stepped up which means a completely new provision is required to be put in place once the patient is medically optimises and ready to leave hospital.
Dedicated hospital discharge services are able to work intensively with patients, their families, clinical staff and community providers to help these patients out of hospital into long terms care as soon as they are medically optimised. Expecting NHS teams to handle these discharge cases in addition to their existing work can cause delays – often these teams are stretched and under resourced.
We’re entering the summer months when system pressures are traditionally lower, but we know this summer, like the last, will be very different from normal – we’re already seeing Covid-19 admissions climbing. Shortly we’ll be considering the collective impact of flu, the elective list activity and Covid-19. A lockdown to manage this scenario will be widely unpopular.
Following more than a year of the pandemic, we have the benefit of understanding future challenges. It’s time to acknowledge that it will take a dedicated workforce solution alongside an integrated approach between public and private healthcare organisations to reach the goals of efficient patient flow and ultimately, a reduction in waiting times for those in need.