Search the hub

In February 2022, NHS England published a plan to recover elective and cancer care over three years from April 2022 to March 2022. Analysing the implementation of this plan to date, the Public Accounts Committee’s has come to the following conclusions and recommendations: 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.

Key findings Introducing access and waiting time standards for mental health services was an important step towards parity of esteem with physical health services. Overall, the number of people treated by NHS mental health services has increased, but some access targets are not being met. The NHS has achieved its waiting times standards, which aim to get people into treatment quickly, for talking therapy services and early intervention in psychosis services, but not yet for eating disorders services for children and young people. NHS mental health services are under continued and increasing pressure and many people using services are reporting poor experiences. NHS England’s ambitious plan for community-based mental health services is still at an early stage. The impact of initiatives to reduce inequalities in mental health is not yet clear. Although the NHS mental health workforce has increased, staff shortages remain the major constraint to improving and expanding services. The share of funding for mental health services has increased slowly, reflecting the pace set by NHSE’s targets Improvements to mental health data and information are taking longer than planned in many areas. DHSC and NHSE have not defined what achieving full parity of esteem between mental and physical health services would mean. Plans for service expansion up to 2023-24 still leave a sizeable gap between the number of people with mental health conditions and how many people the NHS can treat. The national programme, led by NHSE, has maintained a consistent focus on expanding services. Increased demand and disruption following the pandemic mean it is likely to take longer for the NHS to close treatment gaps.

The census had responses from all 12 major Emergency Departments in Wales and found: There is one WTE Consultant per 7784 annual attendances, considerably less than the RCEM recommended figure of 1:4000. Of these 101 consultants, 19 are planning to retire in the next six years – a fifth of the consultant workforce. There were 90 gaps in the consultant rota, 33 in the middle grade rota and eight in the junior rota. Inability to recruit was the primary reason for rota gaps. This is leading to departments in Wales not meeting RCEM best practice recommendations of having an EM consultant presence for at least 16 hours a day in all medium and large systems. When asked for future staffing needs, departments across Wales reported needing an increase of 75% consultants, 120% increase in the ACP/ANP/PA workforce, 44% increase in the ENP workforce, 30% increase in the Higher Specialist Trainees/ Non-consultant Senior Decision Maker and a 50% increase in Junior Doctors in the next six years. The census also found that junior doctors were also being overstretched: At the time of collection there were 52 trainees in the ST1-6 programme as well as 95 non- Emergency Medicine trainees working in EDs across Wales Junior doctors work one weekend every three weekends, consultants work one weekend every 6.2 weekends. Junior doctors in training also do the most night shifts with an average of 52 per year.

Changes in the way staff work, including staff taking on new roles and responsibilities, is a well-known policy solution in the NHS, and there are some really good instances where skill mix works well and has real benefits. But are there downsides to the drive to employ new types of staff to help doctors and nurses? What are the implications for continuity of care, staff experience and outcomes? Is the idea of ‘top of the licence’ working a reason for concern in terms of burnout, the fragmentation of care or is it an unavoidable response to the workforce crisis? Chair: Nigel Edwards, Chief Executive, Nuffield Trust Prof Alison Leary, Chair of Healthcare and Workforce Modelling, London South Bank University Dr Louella Vaughan, Senior Clinical Fellow, Nuffield Trust