This is the first of two blogs by Patient Safety Learning looking at the key patient safety issues faced by the healthcare system in the UK in tackling the care and treatment backlog created by the Covid-19 pandemic. This blog outlines the scale of the challenge and sets out the key patient safety considerations associated with this. It stresses the need for national and local plans to address the backlog, with an emphasis on patient engagement and placing patient safety at their core.
In June last year we outlined the key patient safety challenges faced by the NHS as elective surgery was re-started, following the first wave of the Covid-19 pandemic. We argued that it was crucial that patient safety was placed at the centre of this thinking and set out the action needed to ensure patients were kept safe from avoidable harm.
Subsequently the NHS has borne the brunt of a second wave of Covid over the winter, reducing its capacity to tackle the care and treatment backlog. We are now amid a third wave, driven by the Delta variant, which is again placing immense pressure on NHS capacity, despite the rapid rollout of the UK vaccination programme.
This blog is the first part of our analysis of the key patient safety issues the healthcare system faces in tackling this backlog. Here we first set out the scale of the challenge, considering the additional pressures created by the third wave of Covid and the impact of delays to care and treatment. Then we outline the need for national and local plans to help address the key patient safety issues arising from this and the important role of patient engagement in this process.
Scale of the challenge
The Covid-19 pandemic has created an unprecedented backlog of non-Covid care and treatment. During the first wave in 2020, the decision was taken to postpone all non-urgent elective operations in the UK for at least three months. Subsequently, in the second wave over the winter, while the NHS was able to continue with a significant amount of non-Covid care and treatment, its capacity remained significantly reduced.
A study in the British Journal of Anaesthesia looked in detail at volume of surgical activity and number of cancelled surgical procedures in England and Wales during 2020. It estimates that more than 1.5 million operations had been cancelled across the year. Separately an analysis by the Health Foundation indicated that ‘four million fewer people completed elective treatment pathways in England in 2020 compared with 2019’.
More recently published figures illustrate the scale of the challenge as it stands:
- As of June 2021, there are more than 5.45 million people now waiting for NHS hospital treatment in England.
- Almost 124,000 people have been kept waiting more than three months for diagnostic checks in 2021, compared with 5,675 in 2019.
Meanwhile the Institute of Fiscal Studies has suggested that the waiting list to rise much further, potentially going as high as 15 million by the end of 2025, particularly if the NHS continues to struggle to return to pre-pandemic capacity levels.
Addressing the backlog while in a third wave of Covid
Compounding this challenge is the ongoing pressure from Covid-19 infections as the UK experiences a third wave, driven by the Delta variant of the virus. While the vaccination programme has weakened the link between cases and hospitalisations, it has not been broken, with significant numbers of people needing hospital care.
In their analysis of key areas of pressure in the healthcare system, based on monthly data released by NHS England in June and July 2021, the British Medical Association (BMA) noted the impact that dealing with ongoing Covid infections exerts on addressing the backlog:
‘Infection control measures and the ongoing diversion of resources towards COVID services during the ongoing second peak of hospitalisations mean that this backlog of care will take even longer to work through as it continues to accumulate.’
In the last two months there has been visible evidence of this, with some hospitals being forced to suspend planned operations for several days due the surge in Covid cases.    Further to this, there are other emerging pressures, with rising Accident and Emergency demand and the potential for a future spike in flu and continued rise in Respiratory Syncytial Virus (RSV) infection in the coming months.
While there will never be a perfect set of conditions to confront a challenge of the scale of the existing care and treatment backlog, the current climate is a particularly difficult one. In the meantime, the scale and persistence of this backlog has significant implications for patient safety.
Impact of delays on care and treatment
The impact of the care and treatment backlog varies significantly for patients depending on their health condition and is causing significant patient safety concerns.
Cancer care has been area of much media focus in this regard, with reports highlighting how delays in diagnosis and treatment can result in patients having more progressed cancers when they are identified, becoming harder to treat.   After the first wave of the pandemic, studies suggested that the impact of these delays would result in a significant increase in patient deaths.  Looking at the situation a year on from the first Covid-19 lockdown, an editorial in The Lancet Oncology estimated that around 40,000 fewer people than normal started cancer treatment in the UK in 2020. The All-Party Parliamentary Group (APPG) for Radiotherapy has described this as the biggest cancer crisis in living memory. In a recent report they warned that:
‘There still appears to be no acceptance of the true scale of the backlog or the disruption to the cancer services and no national plan or strategy to address the issues’
Another area of concern is cardiovascular disease. In their recent report, The Untold Heartbreak, the British Heart Foundation highlighted the disruption that the pandemic has caused to prevention, diagnosis and treatment of cardiovascular conditions. Their analysis estimates that the number of people waiting on heart care and diagnosis could more than double in two years in England without decisive action, which risks ‘turning back the clock on 60 years of progress on heart and circulatory diseases in the UK’.
Similar concerns have also been raised around chronic health conditions. Versus Arthritis have called for plans to provide better support for those with prolonged waiting times for elective surgery. They set out how long waits can have a devastating impact on the quality of life of people living with arthritis, who have to manage for longer periods with symptoms such as reduced mobility and significant levels of pain, while many also reporting a general decline of both their physical and mental health during this time.
These are only limited examples of the impact of delays to care and treatment have on patient’s quality of life and, in some cases, their survival.
An urgent plan to address the backlog: national and local
In addressing the backlog, we believe it is vital that the NHS has an approach to prioritising care and treatment that places patient safety at its core. Difficult decisions need to be made that will inevitably have negative outcomes for some patients. So how should these decisions be prioritised?
There has been no shortage of advice to draw on in this area. From within healthcare, organisations such as the BMA, NHS Confederation and NHS Providers have all set out proposals on what is needed to address this.   Suggestions have also come from outside of healthcare, with the think tank Policy Exchange also having recently set out a proposed plan to tackle the backlog.
Whilst we will not seek to prescribe our own over-arching plan for this, we would concur with these organisations that there must be a strategy for tackling the demand on NHS services in a systemic way. We think that there needs to be both national planning and corresponding local plans at the Integrated Care System (ICS) level. We believe these plans should be transparent and made publicly available.
There are several key patient safety issues that such plans should seek to provide clarity on:
- How is the approach to tackling the backlog of care and treatment being coordinated at a national level? It is imperative that there is policy and delivery alignment to ensure that access to care and treatment is based on clinical priority and patient safety.
- Demonstrating fairness and consistency of approach; there should be no tolerance of postcode lotteries of provision or prioritisation.
- There should be information provided on how patient treatment categorisation and priority decisions are being taken. Are these being modelled at a national, regional or ICS level?
- There should be support for clinicians on how they make prioritisation decisions and the governance framework around this.
- There needs to be practical guidance developed to help the NHS cope with the volume of people waiting for elective surgery in a consistent way.
- Some delays will result in higher support needs for those in recovery and/or an increase in comorbidities as patients wait longer for surgery. A national plan should outline how this will be modelled and planned for.
- In some cases, individuals will not receive surgery in a timely manner, with some delays potentially leading to harm or even death. There needs to be clarity on whether when surgery delays lead to significant health issues or even death should be investigated as serious incidents.
- Plans to address the backlog need to outline how patients will be engaged and informed, which we discuss in more detail in the next section.
Importance of patient engagement
Patient Safety Learning believes that engaging effectively with patients is crucial in achieving a patient-safe future, identifying this as one of our six foundations of safe care in our report A Blueprint for Action.
To effectively tackle the backlog of care and treatment and take the difficult prioritisation decisions that this will entail, we believe that there needs to be a clear and effective approach for communicating with patients about delays in their care. The importance of this was also highlighted by the Policy Exchange, who noted that:
‘Current clinical prioritisation and waiting times are hidden from patients. Few are informed about their likely wait time, how this compares to their rights as set out in the NHS constitution, or how the new prioritisation methodology (P1-P4) is being applied to their case’
There needs to be room for honest and candid conversations with patients. As part of national and local plans to tackle the backlog, we believe this requires:
- Proposals on how patients are being engaged in the process or prioritisation. This should include detail around how patients can escalate their concerns and how clinicians will be kept informed of patients’ changing health conditions.
- Guidance to help ensure that when informed of delays or longer waits, patients are signposted to the correct professionals/organisations with any health concerns. Without this, patients’ health might deteriorate, and they are more likely to self-refer to Accident and Emergency or urgent care.
- Plans and funding to mitigate the risks to patients with longer waits for care and treatment.
- Robust measures put in place throughout to ensure that patients access to surgery is needs based and that existing health inequalities are not widened.
The care and treatment backlog in the NHS has significant patient safety implications for patients who have delayed diagnoses or remain for extended periods of time on waiting lists. Depending on their condition, this can have a significant impact on both their quality of life and, in some cases, their survival.
We believe that there is a clear case for developing transparent national and local plans to tackle the care and treatment backlog and that equity and patient safety should be at their heart. These plans must:
- Set out how backlog is being tackled and coordinated at a national and local level.
- Provide information on how patient treatment categorisation and priority decisions are being taken.
- Provide information on how prioritisation decisions are made, what support is available to clinicians for how they make these decisions and the governance framework.
- Be transparent and published in the public domain.
- Set out how patients are to be engaged in the process of prioritisation.
Another key dimension of addressing the care and treatment backlog that we have not touched on here is the role that NHS capacity plays in responding safely to the increased demand. This includes the pressures on both the NHS workforce and wider infrastructure. In Part 2 we will look at this in more detail, considering the impact on those working for the NHS, and how tackling the backlog reinforces the synergy between staff safety and patient safety.
- Patient Safety Learning, The return of elective surgery and implications for patient safety, 15 June 2020.
- Thomas Dobbs et al, Surgical activity in England and Wales during the Covid-19 pandemic: a nationwide observational cohort study, British Journal of Anaesthesia: Volume 127 Issue 2, 17 June 2021.
- The Health Foundation, Long waits, missing patients and catching up: How is elective care in England coping with the continuing impact of COVID-19?, 13 April 2021.
- NHS England and NHS Improvement, Statistical Press Release: NHS referral to treatment (RTT) waiting times date June 2021, 12 August 2021.
- The Guardian, Almost 124,000 patients waiting more than three months for NHS tests in England, 17 August 2021.
- Institute for Fiscal Studies, Could NHS waiting lists really reach 13 million?, 8 August 2021.
- BBC News, Covid hospitalisations could get scary – Prof Chris Whitty, 16 July 2021.
- BMA, Pressure points in the NHS, 24 June 2021.
- BBC News, Covid: Operations cancelled at Birmingham hospital amid rising cases, 17 July 2021.
- The Independent, NHS summer crisis deepens as Covid surge leads to cancelled operations and ambulance ‘black alert’, 19 July 2021.
- The Independent, NHS summer crisis: Hospitals declare ‘black alerts’ as more operations are cancelled, 12 August 2021.
- The Independent, NHS summer crisis: Hospital suspends all inpatient surgery for three weeks over bed shortages, 14 August 2021.
- The Independent, Triple whammy’ of viruses could push the NHS to breaking point this winter, 15 July 2021.
- i Newspaper, Cancer and Covid: ‘Mum died awaiting chemotherapy – I felt the urgency vanished when they found it inoperable’, 10 August 2021.
- Financial Times, NHS cancer services in England struggle to make up ground lost to pandemic, 8 August 2021.
- The Times, Fears breast cancer treatment could slip back years due to the Covid backlog, 15 June 2021.
- Amit Sud et al, Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic, 19 May 2020.
- Cancer Research UK, Over 2 million people in backlog for cancer care, 1 June 2020.
- The Lancet, COVID-19 and cancer: 1 year on, The Lancet Oncology, Vol 22. Issue 4, April 2021.
- APPG for Radiotherapy, Catch Up With Cancer – The Way Forward, 26 May 2021.
- British Heart Foundation, The Untold Heartbreak: Cancelled procedures. Missed appointments. Lost lives, 9 August 2021.
- Versus Arthritis, Supporting people with arthritis waiting for surgery, 23 June 2021.
- BMA, Rest, Recover, restore: Getting UK heath services back on track, 19 March 2021.
- NHS Confederation, Addressing the elective care backlog, 1 June 2021.
- NHS Providers, Addressing the care backlog: An essential partnership between primary and secondary care, 21 July 2021.
- Policy Exchange, A Wait in your Mind? A realistic proposal for tackling the elective backlog, 22 July 2021.
- Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019.