Cancer waiting times are at their worst recorded level and NHS England (NHSE) will not meet its first cancer recovery target. 

Recommendation:

• NHS England should be able to treat 85% of people with cancer within 62 days of an urgent GP referral and no one should ever have to wait more than 104 days for cancer treatment. It is unacceptable that 8,100 people waited over 104 days in the first five months of 2022–23. As a matter of urgency, the Department of Health and Social Care and NHS England should do whatever is required to bring cancer treatment back to an acceptable standard.

NHS England was over-optimistic about the circumstances in which the NHS would be trying to recover elective and cancer care.

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. 

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. 

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. 

Recommendation:

• NHS England must lift its sights and refocus on its strategic duty to offer direction to the whole NHS. This should involve making difficult trade-offs to address historical inequalities between areas, and by having a clear set of actions to improve leadership. To demonstrate progress, NHS England should write to us by the Summer recess setting out the action is has taken to address variation in elective and cancer performance and provide evidence of the impact this has had on patient waiting lists.

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. 

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 assessment.

‘The plan brings together a series of initiatives that, if successfully implemented, will improve access to services for the many patients anxiously waiting for care in pain and discomfort. But, as this plan notes, it is important to recognise that the NHS backlog is bigger than the people waiting for planned hospital care – mental health and community services are also facing backlogs of care, and the pressure on general practice is leaving many people struggling to get an appointment. These services must not be overlooked by a national focus on hospital waiting lists. 

‘The targets in this plan look ambitious, especially as the disruption caused by Covid-19 makes it hard to predict how many patients will need care in the coming months. Analysis by The King’s Fund shows that people living in disadvantaged areas are waiting longer for treatment, so I welcome the recognition that national targets will need to be implemented in a way that rectifies these inequalities.

’More fundamentally, without enough clinical staff these targets will remain aspirational numbers in a plan rather than real change for patients. For many years the NHS has been hamstrung by chronic staff shortages, and today’s plan is a long way short of providing a comprehensive solution. To tackle the staffing crisis, government must move beyond repeating manifesto pledges and instead come forward with a fully funded workforce strategy."

1. Increasing health service capacity, through the expansion and separation of elective and diagnostic service capacity. The physical separation of elective from urgent and emergency services ensures the resilience of elective delivery, as well as providing service efficiency. This will include a strengthened relationship with independent sector providers to accelerate recovery.
2. Prioritising diagnosis and treatment, including a return towards delivery of the six-week diagnostic standard and reducing the maximum length of time that patients wait for elective care and treatment.
3. Transforming the way the NHS provides elective care; for example, by reforming the way outpatient appointments are delivered, making it more flexible for patients and driven by a focus on clinical risk and need, and increasing activity through dedicated and protected surgical hubs.
4. Providing better information and support to patients, supported by better data and information to help inform patient decisions, and in time, making greater use of the NHS App to better manage appointments, bookings and the sharing of information. The NHS will ensure patients have choice at the point of referral, and this will be enhanced for long-waiting patients through a national hub model.

The plan also sets out the following key ambitions:

1. That waits of longer than a year for elective care will be eliminated by March 2025. Within this, by July 2022, no one will wait longer than two years, the NHS will aim to eliminate waits of over 18 months by April 2023, and of over 65 weeks by March 2024. Long-waiting patients will be offered further choice about their care, and over time, as the NHS brings down the longest waits from over two years to under one year, this will be offered sooner.
2. Diagnostic tests are a key part of many elective care pathways - 95% of patients needing a diagnostic test should receive it within six weeks by March 2025.
3. By March 2024, 75% of patients who have been urgently referred by their GP for suspected cancer are diagnosed or have cancer ruled out within 28 days. This will help contribute to the existing NHS Long Term Plan ambitions on early diagnosis. Local systems have also been asked to return the number of people waiting more than 62 days from an urgent referral back to pre-pandemic levels by March 2023.
4. For patients who need an outpatient appointment, the time they wait can be reduced by transforming the model of care and making greater use of technology. The NHS will work with patient groups and stakeholders to better monitor and improve both waiting times and patients’ experience of waiting for first outpatient appointments over the next three years.

• Foreword
• Editorial
• Strengthening health system resilience
• Enhancing participatory governance in health systems
• Transforming delivery of essential health services
• Creating surge capacity and rethinking skill mix
• Supporting and protecting health workers
• Use of digital health tools
• Addressing backlogs and managing waiting lists
• Intensive care capacities during COVID-19
• European Union support for health systems
• Crossing the border for health care
• Towards a European Health Union

1. The Department of Health and Social Care should work with NHS England to produce a broader national health and care recovery plan that goes beyond the elective backlog to emergency care, mental health, primary care, community care and social care. This should be completed by April 2022 and must also set out a clear vision for what ‘success’ in tackling the backlog will look like to patients. In setting those metrics for success, the plan must take account of the risk that a reliance on numerical targets alone will deprioritise key services and risk patient safety. Instead, it must embrace a range of indicators to demonstrate that hidden backlogs are also being tackled and compassionate cultures encouraged.
2. Primary care practices should respond to the needs of their local populations and work with patients to establish the most appropriate method for consultations, based on clinical outcomes. It is not appropriate to set a numerical target for the proportion of appointments carried out remotely in general practice.
3. NHS England should publish its evaluation of the role of digital tools in primary care as soon as possible. It should be used as a basis to produce clear and consistent guidance on best practice in reducing bureaucracy and day-to-day IT administration tasks, and the use of remote consultations in general practice.
4. NHS England should look beyond primary care and consider the impact of increased use of digital tools on patients and other parts of the health and care system, especially at the primary care and secondary care interface.
5. NHS England should complete and publish evaluations of NHS 111 call first services as soon as is practicable, including learning from those evaluations and the implications for any future iterations of the service.
6. Before the end of this financial year, NHS England must publish a Long Covid plan covering the period until 2023. The plan must be developed in consultation with a wide range of stakeholders, including patient groups. NHS England should integrate this into its wider health and care recovery plan, as Long Covid is likely to have implications for demand and workforce across a range of services.
7. The NHS must make a commitment to keeping in touch with patients, many of whom currently feel 'abandoned' by services. This would not just benefit individual patients, but also help local systems actively to manage their lists and inform decisions about prioritisation.
8. The national health and care recovery plan must set out a clear vision for what ‘success’ in tackling the backlog will look like, and what patients can expect their care to look like in their local area in the coming years. The plan must include minimum expectations for integrated care boards (ICBs) in managing waiting lists actively and communicating with patients awaiting planned care. The Department of Health and Social Care, NHS England and local ICBs must share responsibility for communicating the ‘offer’ to the wider public, considering the “social backlog” facing many members of the public. The Select Committee asks the Department of Health and Social Care report back to them on how this will be delivered.
9. The Care Quality Commission should include consultation with patient groups and details of patient outcomes in its assessment of integrated care systems.

• Adopt a relentless focus on ensuring that unknown clinical risks are accounted for by prioritising patients who currently lack a diagnosis.
• Improve transparency, by showing patients how clinical prioritisation methodologies are being applied to them and supporting them whilst they wait.
• Learn the positive lessons of the pandemic in embracing new ways of working across the NHS and with its partners.
• Accept we need to adapt the public conversation around NHS performance relating to elective care to make it more candid, accountable, and open in an era of unprecedented waiting times.

1. Clear communication must be provided to people with arthritis about when they can expect to have their surgery and receive the care and services they need in the meantime.
2. Personalised self-management support must be provided to help people with arthritis manage their pain while they wait for surgery.
3. Physical activity programmes designed to help people with arthritis stay active and prepare for surgery should be actively promoted by Primary Care Networks.
4. Mental health support should be offered to help every person with arthritis to manage their pain and any associated depression and anxiety.
5. Signposting to financial support and advice should be provided for people with arthritis in work or seeking work.
6. Covid-19 recovery plans should include the specific needs of people with arthritis.

• The sustained impact of the pandemic will leave a backlog of care in excess of anything seen over the last 12 years. Although urgent and emergency procedures have largely been maintained, much of the growth in waiting lists comes from low priority, high-volume procedures for conditions ranging from painful bone and joint conditions, to ear, nose and throat and ophthalmology.
• Our modelling suggests that to maintain any sense of control over the NHS waiting list, the NHS will need to increase capacity considerably above levels than have previously been sustained. Our members are embracing best practice, as represented by the Getting It Right First Time programme (GIRFT), and innovating to support waiting list management but will need further support to make inroads into the backlog. 
• The existing framework for elective care, which is based around organisations and tariff, is widely accepted as not being fit for purpose to resolve growing lists and the increasing backlog. Without a comprehensive new plan, the government faces the politically unacceptable legacy of hundreds of thousands of patients left on waiting lists with deteriorating conditions for the remainder of the parliament.
• Our members want to see whole-system thinking to manage waiting lists between trusts, and deeper partnerships with primary and community care, supported by real-time patient data. Small amounts of quick capital will help to create ‘hot and cold’ hospital sites, which will increase efficiency, while funding support for the voluntary sector will help patients to receive more care and support as they wait for their procedures.
• The intensity of the pandemic response has had a marked impact on NHS staff and left the healthcare workforce in a fragile state. In many areas, the same group of staff who have worked through the pandemic, and who are delivering the vaccination programme, will be asked to step up once again to recover backlogs. Any plan that fails to recognise this is unlikely to succeed.
• The additional £1bn agreed in the Spending Review for 2021/22 will not be enough to clear the backlog. The healthcare sector will need honesty from political leaders to help manage the inevitable change in public opinion when there are further delays in treatment.
• By creating a long-term framework for the recovery of elective care that is efficient, patient focused and equitable, the NHS can make fast progress on recovering its elective care position. As part of that, it will be important to rethink the way that waiting lists are measured, as many of the performance standards are no longer fit for purpose.
• This briefing focuses on the elective backlog. Similar pressures will be faced across the NHS, from a surge in demand for mental health support, to increased need for community services and increased demand on primary care.
• While our members are innovating and driving service improvement at local level, more support is required from government in its public messaging. This would help the NHS to clarify priorities and facilitate an honest public debate on the scale of the challenge and the measures to resolve it. 

Download the full briefing via the link below or the attached document.