How can the independent sector play its role in NHS elective recovery?

It arrived several weeks later than initially planned due to Omicron and was prefixed in the days before launch with political tension over its scale of ambition, an issue which is likely to become even starker when the planned National Insurance rise kicks in this April, but finally on Tuesday of this week the government and the NHS launched their plan for tackling the Covid-19 backlog of elective care which has built up as a result of the pandemic.

The first thing to say about this is that whilst the elective backlog is clearly critical and carries enormous significance both for those on the list and for politicians, it is not the only part of the system to be under severe strain. Pressures in primary care, mental health and community services are also very evident and there will need to be real focus on these areas too if the public’s experience of the NHS is not to deteriorate.

But in elective care – where the data is probably the most high-profile – the numbers are stark.

Only yesterday (Thursday 10 February) NHS England reported that the overall size of the waiting list had grown to 6.1m, up from 4.4m in December 2019. 2.2m (37% of the total) are now waiting longer than 18 weeks for treatment, 1.4m (24%) are waiting longer than six months and 311,000 (5.4%) are waiting longer than a year.

Some of the increases are staggering and whilst inevitably attention focuses on those waiting longer than 52 or 104 weeks, it is also the case that the numbers waiting longer than 18 weeks are up a dizzying 200% on where they were in 2019. That is a lot of people waiting longer for treatment than would have been the case just two years ago.

And whilst up on 2020 levels completed admitted pathways were still down 11% when compared to 2019 and completed non-admitted pathways were down 3%, starkly illustrating the challenges facing the NHS in getting activity back above pre-pandemic levels.

So what is to be done?

The elective backlog plan contains some good ideas to help meet the overall objectives of getting the waiting list falling by March 2024 (a timetable that has certainly alarmed some government backbenchers) with interim targets along the way for the longer waiters, and helpfully much of what is captured in the plan is already in train to a greater or lesser extent, although the need for a much clearer workforce strategy is stark.

One of the areas which was clearly described in the plan however was making use of independent sector capacity to help drive up activity levels across the country and it is now vital that we see a real gear change in the way that the NHS uses the independent sector to assist with elective recovery.

Whilst the NHS’ data in this area isn’t always consistent, the general trend of the last 12 months has been for NHS-funded ophthalmology activity in the independent sector to be well above pre-pandemic levels with other areas including orthopaedics, general surgery and gastro all falling when compared to 2019.

Given that the government and the NHS is aiming for NHS-funded activity to be at 130% of pre-pandemic levels by 2024/25 and there are significant challenges for NHS providers of reaching this level of activity given the pressures they face, it is clear that independent sector activity needs to increase considerably on where it is now to help deliver the government’s objectives.

Experience from the 2000’s – arguably the last time that a government set out such a clear NHS role for the independent sector as occurred this week – tells us that there are some very clear policy, operational and commercial enablers which must be in place to drive increased activity.

Firstly political timidity won’t help. There will always be a small, vocal, minority who describe any NHS patient being treated in the independent sector as “NHS privatisation”. In recent times, governments have been too defensive in responding to these criticisms with each political side keen to say that they have not increased the role of the private sector in the NHS. All this does is to send a clear message that you’re not serious about doing everything possible to improve access to NHS treatment. The public are grown-up about this issue and most are entirely comfortable being treated in the independent sector provided the service is good and the treatment remains free at the point of use. As it did this week the government needs to continue to be open and honest with the public that the independent sector has a significant and positive role to play.

Secondly it needs to be made as smooth and straightforward as possible to get NHS patients into independent sector providers. Referrals out of General Practice directly into independent providers, supported by a robust patient choice regime, represents an effective, non-bureaucratic way of getting patients referred. But the process of transferring patients from Trust waiting lists into independent sector providers needs to be made much slicker with whole cohorts and pathways shifted over on a medium to long term basis rather than dribs and drabs of patients sent across ad hoc. The proposed ‘long wait hubs’ referenced in the backlog recovery plan should play a major role here.

Thirdly the payment regime is an important success factor. Payment by Results and the introduction of the NHS tariff played a critical role in incentivising activity in the 2000’s and it needs to do so again. At the moment the NHS tariff is largely applied only to the independent sector whilst NHS Trusts work off block contracts. That mismatch in incentives has been a problem locally throughout 2021/22 and the decisions which NHS England make about payment mechanisms going into 2022/23 will be critical.

Fourthly there are some important issues to resolve within new ICS structures around governance and decision making. One of the advantages of a clear purchaser/provider split – a feature of NHS policy making for a generation but being unwound through the Health and Care Bill – is that decisions around where patients are treated are disconnected from provider decisions about how to attract revenue. With NHS providers likely to be making major funding and commissioning decisions through their statutory role on Integrated Care Boards resolving clear potential conflict of interest issues must be a priority.

Fifthly if the NHS wishes the independent sector to invest significant capital in new services and facilities – as it did in the 2000’s through the Independent Sector Treatment Centre programme – then this needs to be clearly spelled out and driven hard from the centre. Some good work has been done on the development of Community Diagnostic Centres in attracting independent sector partners but this programme would benefit from an injection of pace and could credibly be replicated with a plan to secure more surgical capacity. Investment is available in the market to do this but it does require a long-term view, something which the backlog recovery plan acknowledged was important but upon which detail was light.

Any problem as complex and difficult as recovering NHS services after a global pandemic will not have a simple solution and of course the independent sector is no silver bullet. But history has shown that with a clear set of objectives, consistent policy application and a positive attitude to partnership, that the sector can be effectively harnessed as part of a wider system to play a major part in improving patients access to and experience of NHS treatment.

This week’s backlog recovery plan is a fine start on that journey but in many ways the hard work starts now.

David Hare, Chief Executive, Independent Healthcare Providers Network