Managing NHS backlogs & waiting times

NHS England was over-optimistic about the circumstances in which the NHS would be trying to recover elective and cancer care. In our first report on NHS backlogs and waiting times in March 2022, we reported our concern that “officials are too optimistic about the resilience of NHS services in the short- and medium- term, particularly as NHS staff have been working under continuously high pressure during the pandemic”. The recovery plan, however, continued this over- optimism by including assumptions about low levels of COVID-19 and minimal winter pressures, and that activity levels would recover to pre-pandemic levels early in 2022–23. Between April and August 2022, elective activity was at just 95% of pre-pandemic levels. The reality has been that the NHS continues to manage other major pressures, including ongoing effects of COVID-19, access to primary care, the performance of urgent and emergency care, workforce gaps, and problems with the supply of adult social care. NHSE told us that it would need to “reprofile” the trajectory of the recovery if it was to reach 129% during 2024–25. Macmillan Cancer Support and Healthwatch Suffolk submitted evidence to us with powerful examples of the uncertainty, anxiety and other problems experienced by long-waiting patients. Recommendation: NHS England and the Department of Health and Social Care should revisit their planning assumptions for the recovery and publicly report any updates to targets so that patients and NHS staff can see a clear and realistic trajectory to achieve the 62-day cancer backlog target, the 52-week wait target for elective care, and, ultimately, the 18-week legal standard for elective care.

NHS funding has increased, but to deliver key priorities such as elective and cancer recovery it will need to be spent in the most cost-effective way. The Department has allocated £14 billion to NHSE from 2022–23 to 2024–25 specifically to recover elective and cancer care. This comprises £8 billion of resource funding and £5.9 billion of capital funding. The Autumn Statement 2022 committed an additional £3.3 billion in 2023–24 and 2024–25 to the NHS budget as a whole. NHSE told us this would be sufficient for the NHS to deliver its key priorities. However, NHSE 6 Managing NHS backlogs and waiting times in England has opted not to produce a detailed costed version of its recovery plan to show how it expects all of the £14 billion to be spent. Without timely evaluation of its programmes, including surgical hubs and clinical diagnostic centres, there is a risk that the future allocation of resources will not be informed by reality on the ground. Overall, the NHS has a problem with reduced productivity. An internal review by NHS England estimated that the NHS was around 16% less productive in 2021 than in 2019 and said that the immediate effects of the pandemic were not the only cause. Recommendation: NHSE should transparently describe how the additional funds for elective recovery have been allocated. Alongside the Treasury Minute response, it should also write to us providing details of the programmes on which it expects the £14 billion to be spent, the independent evaluations it has put in place to monitor the effectiveness of additional spending, and how it expects additional spending to improve NHS productivity.

NHS England’s elective recovery programme partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness. NHSE has expanded some programmes because it believes them to be sufficiently promising, but there is currently a limited evidence base for their effectiveness, their impact on other parts of the health and social care system, and how they will work on a greatly expanded scale. NHSE told us it would ensure that capacity in surgical hubs, community diagnostic centres and the independent sector would be genuinely additional. However, it has more work to do to demonstrate how additional capacity will be sufficiently staffed without detracting from other NHS services. It is also concerning that NHSE could not provide the National Audit Office with its full evaluation of the 2021 elective accelerators programme, on which it spent £160 million. Recommendation: NHS England should know more about the conditions necessary for individual programmes to make the greatest contribution possible to recovery. Alongside its Treasury Minute response to this report, it should write to us more fully describing the real-world impact of community diagnostic centres, surgical hubs, increased use of the independent sector, and the advice and guidance programme. It should set out its understanding of the extent to which these initiatives have so far generated genuinely additional activity, rather than simply displacing activity elsewhere in the NHS.

NHSE started 2022–23 with a strategy but spent most of the year dealing with tactical issues and its strategic and programme management of the recovery must improve. NHSE was allocated £14 billion of recovery funding in September 2021 (for the three years from April 2022) and published its recovery plan in February

The NHS’s recovery cannot succeed without comprehensive, realistic and sustainable plans for the future of the workforce and the capacity of adult social care. The Royal Colleges of Radiologists, Surgeons, Nursing, Obstetricians and Gynaecologists, and Ophthalmologists all submitted evidence to us stressing the need for strategic workforce planning. In our March 2022 report on NHS backlogs, we stated that “the NHS will be less able to deal with backlogs if it does not address longstanding workforce issues”. Deferring action on this means not making the best use of the NHS’s existing hardworking and committed frontline staff. It is also clear that the success of the recovery programme is reliant on realistic long-term planning in other areas of health and care, including the capacity of adult social care where this is reducing flow through hospitals. The Department confirmed some of the steps it will take immediately, including to publish an independently verified forecast of the number of health professionals the NHS requires during 2023 and to allocate additional funds to improve hospital discharge into adult social care. These are not end-points, however, and results of this work must be incorporated into realistic planning assumptions for NHS elective and cancer recovery. Recommendations: • The Department of Health and Social Care should work with NHS England to reassess the achievability of elective and cancer recovery targets following the publication of its workforce plan in 2023, and planned improvements to the discharge of patients into adult social care. It should write to us as soon as possible describing the conclusions of this achievability assessment. • The Department should publish the underlying assumptions of its workforce projections alongside the forecasts in the workforce plan. This should include quantification of key assumptions, particularly on productivity, domestic training and overseas recruitment and, in full, the independent reviewer’s ass

On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England (NHSE) about NHS backlogs and waiting times in England.1

In July 2022, the Chief Executive of the NHS, wrote to all Chief Executives of NHS trusts, NHS Foundation Trusts and Integrated Care Boards stating that the 62-day cancer backlog target should be a critical priority for the remainder of the year.13 This instruction has not led to the results NHSE hoped for. In our session NHSE had to acknowledge that it no longer expected to meet the target by March 2023.14 Over-optimism in recovery assumptions

This Committee first looked at post-pandemic backlogs in December 2021, publishing our report in March 2022. We noted that officials appeared to be planning on the basis of optimistic future scenarios and also that there was general over-optimism from officials on the short- and medium-term resilience of the NHS.15 The latest National Audit Office report states that the recovery plan contained over-optimistic assumptions about maintaining low levels of COVID-19 in 2022–23 and suffering minimal adverse effects from winter pressures.16 It notes that NHSE’s internal target for completed elective pathways in 2022–23 was 102% of the pre-pandemic level, but actually elective activity was at just 95% of pre-pandemic levels in the first five months of 2022–23.17 Put simply, this means that the elective recovery is already off track.

We asked NHSE about its optimism at the time it agreed the recovery targets. It told us that its assumption about low levels of COVID-19 had turned out to be “completely wrong”. It added that this had resulted in both a higher than anticipated demand for hospital beds for patients with COVID-19 and higher staff sickness absence.18 The National Audit Office report states that the NHS is also managing other major pressures, 7 C&AG’s Report, paras 16, 3.12, 3.13, Figure 11, Figure 12 8 C&AG’s Report, paras 16, 1.8, 3.12, 3.13. 9 Quarterly data available at: https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2022/12/Cancer- Waiting-Times-National-Time-Series-Oct-2009-Oct-2022-with-Revisions.xlsx 10 C&AG’s Report, Figure 5. 11 Q 44 12 C&AG’s Report, para 16, 2.14 13 Available at: https://www.england.nhs.uk/wp-content/uploads/2022/07/B1881_Next-steps-in-the-recovery-of- elective-services_July-2022.pdf 14 Q 44 15 Committee of Public Accounts, NHS backlogs and waiting times in England, Forty-Fourth Report of Session 2021–22, HC 747, 16 March 2022 16 C&AG’s Report, para 3.2 17 C&AG’s Report, paras 14, 3.3 18 Q 11 10 Managing NHS backlogs and waiting times in England including other ongoing effects of the COVID-19 pandemic, access to primary care, the performance of urgent and emergency care, workforce gaps, and problems with the supply of adult social care.19

We shared our concerns about the risks facing the NHS and its ability to deliver the recovery targets and we pressed NHSE on how confident it was that it would meet the target to increase elective activity to 129% of 2019–20 levels by 2024–25.20 In some ways, this is the most important target because increasing activity is what will enable all the other targets to be met. We noted the importance of reaching higher levels of activity as soon as possible so as to begin reducing the backlog of people waiting for elective care. NHSE told us that it continued to aim for 129% in 2024–25 but that it recognised it would need to “re-profile” its trajectories for getting there.21

Macmillan Cancer Support and Healthwatch Suffolk submitted evidence to us containing powerful examples of the uncertainty, anxiety and other problems long waits cause patients. Macmillan Cancer Support told us that the impact of cancer care backlogs was being felt by people at all stages of the cancer pathway and that people were worried about a reduced chance of surviving cancer because of the delays.22 On elective care, Healthwatch Suffolk told us of the wider, often long-term impacts that treatment delays can have, including people having to live with increased pain and experiencing detrimental effects on their mental health, social life, and wellbeing.23 19 C&AG’s Report, para 2 20 Q 13 21 Q 14 22 NHS0033 23 NHS0008 Managing NHS backlogs and waiting times in England 11 2 Ensuring effectiveness of recovery plans Additional spending

The Department has allocated £14 billion to NHS England from 2022–23 to 2024–25 specifically to recover elective and cancer care, comprising £8 billion of resource funding and £5.9 billion of capital funding, as described in the November 2021 Budget and Spending Review.24 The Autumn Statement in November 2022 then, separately, committed additional funding to the overall NHS budget due to financial pressures. NHSE’s planned resource limit for 2024–25 is now £166 billion: “£3.3 billion in each of the next 2 years to support the NHS in England in response to the significant financial pressures it faces, and [enable] rapid action to improve emergency, elective and primary care performance”.25

We asked NHSE about whether, in its view, this would provide the NHS with sufficient funding, given its previous comments about the scale of the negative impact inflation had had on its budgets.26 The Chief Executive told us that it should be enough to deliver key priorities, including elective and cancer recovery. NHSE also listed the continuing risks to recovery, many of which could reduce the value of this latest spending settlement: these include, in particular, risks relating to industrial action, and any increases in the assumed level of inflation.27 The National Audit Office report notes that NHSE has so far opted not to produce a detailed costed version of its recovery plan to show how it expects all of the £14 billion to be spent.28

NHSE has estimated that the NHS was around 16% less productive in 2021 than before the pandemic.29 NHSE’s internal analysis indicated that this drop in productivity was not solely due to immediate pandemic pressures, but also resulted from staff being less likely to work paid or unpaid overtime, and a reduced management focus by NHSE and NHS trusts on cost control and operational rigour.30 In responding to our questions about how it is practically addressing the productivity problem, NHSE said that the work had to begin at the level of individual providers. It told us that a provider should begin by working through available data to understand the specific issues it was facing, in order to come up with a plan to improve productivity. It indicated that it would be leading this kind of process throughout the country during the next annual planning round.31 New programmes and initiatives for recovery

NHSE’s elective recovery programme includes plans for: • GPs to handle many elective cases previously dealt with by hospital doctors. Instead of referring some patients for elective care, GPs manage them within the 24 C&AG’s Report, paras 7, 1.15; Autumn Budget and Spending Review 2021, para 2.11 25 Autumn Statement 2022, para 5.57, table 2.1 26 NHS England Board Paper, 6 October 2022 27 Q 105 28 C&AG’s Report, paras 7, 1.23 29 C&AG’s Report, paras 13, 3.21 30 C&AG’s Report, para 3.21 31 Q 96 12 Managing NHS backlogs and waiting times in England primary care system after receiving advice and guidance from hospital doctors. The recovery plan aims for 1.7 million elective referrals to be avoided in this way in 2022–23, rising to 2.0 million in 2023–24. • Surgical hubs and community diagnostic centres which contribute to elective recovery by improving efficiency and access to services. These two programmes may provide resilience by allowing elective care to continue on physically separate ‘cold sites’ when other parts of hospitals struggle with high rates of bed occupancy or other kinds of patient demand.32

We asked how confident NHSE was about the component programmes in its plan, particularly those aimed at increasing elective and diagnostic capacity. It told us that it did not have strong evidence for some of its programmes at present, but said it was building evaluation into its programmes on surgical hubs and community diagnostic centres.33 It said “the basis of a formal evaluation is clearly in place”.34 We hope that NHSE will take this responsibility to evaluate seriously. These are promising programmes but they must prove themselves in practice. We were concerned that NHSE had been unable to find its evaluation of a previous programme, elective accelerators, which provided £160 million to 12 local systems in 2021. The systems were supposed to increase their elective activity but in practice activity still fell short of pre-pandemic levels.35

Surgical hubs and community diagnostic centres have potential, but success will rely on them being adequately staffed. NHSE currently has limited evidence on hubs’ and CDC’s ability to continue operating when the wider NHS is under significant pressure.36 The Royal College of Surgeons also acknowledged the value of a thorough evaluation of surgical hubs, stating that “whilst the underpinning theory for surgical hubs is sound, and there are examples of good practice, we recognise the need for more empirical evidence to confirm the extent to which surgical hubs can increase productivity, and also to consider their wider impacts”.37

We also asked NHSE whether its increased use of the independent healthcare sector might detract from or reduce activity within the NHS itself. NHSE told us that this was a key consideration in decisions about when to use the independent sector. It confirmed that it was working to support NHS and independent sector providers to work as productively as possible together.38 32 C&AG’s Report, para 8, 1.24 33 Q 61 34 Q 62 35 C&AG’s Report, para 1.25 36 C&AG’s Report, paras 8, 2.22, 2.29 37 NHS0021 38 Qq 67, 69 Managing NHS backlogs and waiting times in England 13 3 Improving planning Improving strategic and programme management

We asked NHSE about its programme management of the recovery and its strategic approach to tackling variation in performance between NHS areas. The National Audit Office found that, whilst recovery funding was allocated in September 2021 and the recovery plan published in February 2022, NHSE had only filled seven out of 21 posts in its central programme management office by the end of May 2022. It also reported that NHSE still did not have the capability to report fully on performance, according to the measures it had itself identified, in August 2022.39

NHSE told us that it monitored performance constantly, with fresh data available weekly, and that it was continually developing the metrics it uses to track performance. It argued that this was a comprehensive and agile approach.40 We heard how NHSE uses data to place NHS providers into tiers, depending on how on or off track they are against targets. It then seeks to provide greater support to those organisations that are more off track, including sharing best practice from other areas.41

In response to our question about improving areas that have seen long-term underperformance, sometimes dating back to before the pandemic, NHSE told us that it had sent teams into some areas to support and challenge them.42 The National Audit Office report showed that the proportion of waiting patients who are in scope of the target to eliminate 78-week waits by April 2023 ranges from 2% to 20%, depending on the part of the country. This means that the challenge of meeting the target is vastly harder for some parts of the NHS than others.43 Key dependencies including workforce planning

This report is the Committee’s second on NHS backlogs, the first being published in March 2022. We stated then that “the NHS will be less able to deal with backlogs if it does not address longstanding workforce issues”.44 For this inquiry we received evidence from five medical Royal Colleges. The submissions from the Royal Colleges of Nursing, Obstetricians and Gynaecologists, Ophthalmologists, Radiologists, and Surgeons all highlighted the ongoing absence of sufficient strategic workforce planning.45 The Autumn Statement 2022 confirmed that a workforce plan, with quantified workforce projections, would be produced by the Department in 2023: “the government is publishing a comprehensive NHS workforce plan, including independently verified workforce forecasts, next year. This will include measures to make the best use of training to get doctors, nurses and allied health professionals into the workforce, increase workforce productivity and retention.”46 This is a welcome and long overdue step. 39 C&AG’s Report, paras 9, 2.7 40 Q71 41 Q72 42 Q 73 43 C&AG’s Report, para 2.12, Figure 7 44 Committee of Public Accounts, NHS backlogs and waiting times in England, Forty-Fourth Report of Session 2021–22, HC 747, 16 March 2022 45 NHS0002, NHS0015, NHS0019, NHS0021, NHS0026 46 Autumn Statement 2022, para 5.59 14 Managing NHS backlogs and waiting times in England

We asked the Department if it agreed that it was more sustainable to train more doctors, nurses and other health professionals domestically, rather than be over-reliant on international recruitment. It told us that this question would be part of the review that will lead to the workforce plan it will release in 2023.47

We asked about other key enablers of a successful recovery of elective and cancer care. NHSE told us about the particular negative impact of delayed discharges into adult social care, which had reduced its effective inpatient capacity.48 The Department confirmed that the additional funding for adult social care announced in the Autumn Statement would be used to help improve “the flow through from hospital to care.”49 The Autumn Statement 2022 committed to “an additional £1 billion of central government funding in England in 2023–24, increasing to £1.7 billion in 2024–25, to get people out of hospital on time and into social care.”50 47 Qq 106, 108 48 Q77 49 Q111 50 Autumn Statement 2022, para 5.61 Managing NHS backlogs and waiting times in England 15