David Oliver: Can the recovery plan for elective care in England deliver?

Even before the covid-19 pandemic hit the UK in 2020, waiting lists for elective outpatient appointments, investigations, and procedures were growing. Covid has rapidly increased already long waiting times. Across the four UK nations we now face longer waits and more patients on lists than in decades, including more than six million in England.1 There’s also concern that millions of patients are potentially missing from lists, who would ordinarily have been booked in pre-pandemic times.2

In response, NHS England, with a strong push for action from ministers, last month published the Delivery Plan for Tackling the Covid-19 Backlog of Elective Care.3 The plan is ambitious and rich in targets. Overall, it states the need for an increase in activity of 30% above pre-pandemic levels by 2024-25 to reduce waiting times. But how will this be achieved? A 30% rise is a steep increase, especially with a depleted and tired workforce. No sooner had the plan been published than the NHS started to see a resurgence in acute covid admissions after the government had lifted all protection measures.4

The recovery plan aims to create dozens of diagnostic and surgical hubs, physically separate from main hospital sites that are susceptible to acute demand surges, to include and co-opt additional private sector capacity. An elephant in the room is that the UK, and England in particular, has among the lowest general hospital and intensive care bed capacity per head among developed countries, with hospitals routinely full.56

The plan also calls for a redesign of outpatient care delivery and a move away from wasteful practices such as routine follow-ups in stable patients, cancellations, or “no shows,” as well as from low value physical appointments, where perhaps referral wasn’t required or where telephone or online advice would have been more efficient.

More emphasis is placed on patient involvement and self-direction, more direct access to clinical staff for direct consultation, more explicit prioritisation of cases, and greater use of digital technology such as booking apps. Some targeted funding streams have been set up to aid this improvement and innovation, although much of the money announced was already budgeted for.

The stumbling block with all of this is the “who?” We don’t yet have an NHS workforce plan. The health secretary has already made clear in a speech that any increase in clinical workforce numbers will need to come from existing funds.7 Huge vacancy numbers already exist across a range of clinical disciplines.8

Yes, the report does mention visa changes and a recruitment drive to add thousands of support workers, nurses, and allied professionals. It mentions workshops to discuss pension rules, to deter people from retiring or reducing clinical sessions because of fears over pension liability. But to deliver gains of the size promised we need more staff in a variety of disciplines: doctors, radiographers, clinical scientists; advanced nurse practitioners, nurses for surgical wards, day units, and intensive care; and more allied health professionals to work in outpatients and postoperative care. Where are these going to come from, and what are they going to stop doing to prioritise delivering recovery?

The workforce gaps and the reality that it takes years to train senior clinicians are the plan’s Achilles’ heel, and it’s too early to predict how well some of the proposed innovations will work. Only three weeks after the plan was announced, the Nuffield Trust published a report comparing how 16 countries responded to the very real problems many of them are facing in delayed elective care during the pandemic.9 A headline conclusion was that the UK had gone into the pandemic with more deep seated problems in workforce numbers, equipment, beds, and existing pressures than most of the others.

For the sake of patients, colleagues, and the NHS’s future, I want elective recovery to work. But I have my doubts as to whether it will.