Elective recovery plan at risk as inflation and workforce shortages take their toll

At the start of the Covid-19 pandemic the NHS had not met its standard for elective care for four years nor its full set of eight standards for cancer services for six years. And the pandemic has exacerbated problems with the waiting list for elective care growing from 4.4 million in February 2020 to more than seven million now. Workforce shortages and pressures in social care have made major contributions to the worsening position.

The financial watchdog’s report – Managing NHS backlogs and waiting times in England – said that the NHS England plan to increase elective activity to 129% of 2019/20 levels by 2024/25 would be a historic achievement, given it previously took five years to increase activity by 18%. And even then, it was ‘unclear’ that the 129% level would be sufficient to meet all the commitments in NHS England’s recovery plan, published in February this year.

Meg Hillier (pictured), chair of the Commons Public Accounts Committee described backlog recovery as a ‘monumental challenge’ and said the committee had previously warned the government against over-optimistic plans.

‘The NAO’s latest report shows that NHS England’s recovery programme for elective and cancer care is very ambitious, reliant on innovative but relatively untested approaches, and already falling short of expectations,’ she said. ‘Patients will continue to suffer the consequences if NHS England doesn’t act now to improve its management of the programme.’

That recovery plan focuses on eliminating the longest waits. So, by March 2025, no patient should have been waiting more than 52 weeks for elective care, and by March 2023 waiting times for urgent GP referrals for cancer care should have returned to the pre-pandemic level. While these targets would be a significant improvement on current performance, they are a long way short of the standards for waiting times set in NHS regulations. For example, the target for elective care is 18 weeks.

To be on course for the 129% target, the NHS needs to deliver 102% of 2019/20 levels of patients treated this year (measured in completed elective pathways). But in the first five months of the year, it had delivered just 95% of activity compared with the same months in the baseline year. Using a metric of value-based activity – which factors in the different costs of different types of elective activity – systems would need to deliver 104% of the 2019/20 level. However, in their plans, 26 of the 42 integrated care systems signalled that they would not reach this target.

Systems have been incentivised to exceed target levels of activity using the elective recovery fund and the variable element in the new aligned payment and incentive payment scheme. However, the scheme could also see funding withdrawn for underperformance. The NAO said that uncertainty about whether money could be lost later in the year might even be further inhibiting progress with elective recovery. Systems may be reluctant to pass all the work they could to independent sector providers as this work would need to be paid for even if funding available to cover it was subsequently clawed back.

The government allocated £14bn specifically to the recovery plan in the October 2021 Budget. This included £8bn for revenue spending and £5.9bn for capital between the years 2022-23 and 2024-25. However, inflation has eroded both the specific elective recovery funding and the wider planned increases in the NHS England budget.

The report also highlighted concerns with a 16% drop in productivity since before the pandemic. Some of this was related to increased sickness absence and infection control measures. But an internal NHS England review had also identified a range of other causes including reduced willingness to work paid or unpaid overtime.

Gareth Davies, head of the NAO, said there were significant risks to the delivery of the recovery plan. ‘The NHS faces workforce shortages and inflationary pressures, and it will need to be agile in responding as the results of different initiatives in the recovery programme emerge,’ he said.

The watchdog called on NHS England to improve its reporting indicators with new measures to take account of key risks and critical enablers such as workforce availability. The major elective recovery programmes should be independently evaluated to develop an evidence base for what works.  And it called for a review of recovery targets and trajectories in the first quarter of 2022/23. This would determine the need for any adjustments and how to allocate future funding.

It also asked NHS England to publish a report next year on the progress being made with the recovery programme and to consider publishing this annually. And then the Department of Health and Social Care and NHS England should develop a long-term plan for returning to the published waiting time standards.

Matthew Taylor (pictured), chief executive of the NHS Confederation, said the government needed to act quickly. ‘This is really concerning for frontline staff, who have worked very hard to make sure that virtually everyone who had been waiting for two or more years for a planned procedure got one before the government’s July target, he said. ‘With winter on the horizon and without more support, they simply don’t have the time or capacity to do more.’

Nuffield Trust deputy director of research Sarah Scobie said the report depicted ‘an NHS on its knees’, trying to address the backlog in the face of huge pressures everywhere else. ‘The urgent care system is at breaking point, with ambulances backed up outside hospitals and major problems in discharging patients into their own homes or care homes,' she said. 'The NAO report offers the right mix of solutions and proposals to tackle the backlog. But doing this in the face of such knotty and persistent problems will be no easy feat.’