The planned care crisis and opportunity

Introduction

Covid-19 has generated an unprecedented challenge for the UK healthcare system, with a particular pressure on planned care services. By the end of December, it is estimated that ~9.8m patients will require treatment, which is more than double the number of patients on the official waiting list at the start of March.

As healthcare providers across the entire country are expected to stop this demand from rising, and in fact begin reducing it, they must drive a step-change in efficiency to beyond pre-Covid levels. The independent sector has commenced this journey by quantifying the impact of Covid on planned care delivery and, using insights from this analysis, charting a course for recovery. The NHS has also undertaken work to meet this unprecedented challenge and, therefore, the two sectors now need to work collaboratively and share their respective learnings to address this crisis collectively.

In the long-term, if providers overcome the crisis effectively, they will be in a position to achieve radical transformation in planned care delivery, reaching new levels of quality of care and patient safety.

In this article, we examine the magnitude of the challenge faced in planned care services, the work undertaken so far by the independent sector from which other providers can learn, and the post-Covid opportunity for all healthcare providers across the country.

Understanding the context and magnitude of the challenge

In the three years leading up to Covid in March, the number of referrals into planned care was rising, and, with a delayed increase in patients starting treatment, waiting times were on the up. Performance, as captured by the percentage of patients waiting no more than 18 weeks from referral to treatment (RTT), was in gradual decline (see Exhibit 1).

Since Covid hit in March, the challenge for planned care activity has intensified. The entire health sector moved rapidly to develop an effective response to Covid which included scaling back planned care activity significantly in both the NHS and the independent sector.

At the time, given the Covid challenge, this was a vital step, but we are now facing the consequence: an increased “backlog” made up of two types of patients. First are those in the system waiting longer than ever before to access care, and second are those not yet in the system but who would have been diagnosed and referred, had planned care services not been disrupted.

As seen in Exhibit 2, from March to July, the treatment rate – defined as the number of patients starting treatment – dropped by ~45% year-on-year and waiting times for patients were beginning to rise, even as the total number of patients waiting for treatment actually fell.

This, however, is not the full picture because the number of referrals over this period also dropped, by about 50%. By accounting for these “missing” referrals which will likely enter the system at some point (calculated using a historic rate over the same period in 2019), the estimated true demand by the end of July has increased from March by about 85%, to approximately 8.2m (see Exhibit 3).

Given the comprehensive publicly available records of activity, it is a simple exercise to project forward. By December 2020, even if we assume some recovery of the treatment rate from the post-Covid lows[1], the true demand including “new referrals” (again calculated using the historic rate) will be nearly 10m (see Exhibit 4). Similar figures have been estimated by other organisations, including the NHS Confederation as published by the BBC in early June.

The prospect of nearly 10m patients requiring treatment in December, which is double the official waiting list in March, is an unprecedented challenge. Overcoming such a challenge will require the coordinated, extraordinary efforts of both NHS and independent providers and their dedicated teams.

The entire sector must first focus on recovering throughput to 100% of pre-Covid levels by addressing the delays caused by Covid to prevent the “backlog” from continuing to rise. However, in order to actually begin reducing the “backlog”, the sector will have to drive throughput to exceed pre-Covid levels. A reasonable target may be 120% which will have to be achieved through broadening the scope of improvement (see final section).

Understanding the root causes in granular detail as the first step to recovery

The next section draws from work completed by the independent sector to understand the impact of Covid on planned care activity

When the independent sector set out to resume planned activity in June, it also undertook a comprehensive and critical analysis of its own operations to understand the intrinsic drivers of the challenge in granular detail, quantify their impact, and utilise insights from this analysis to chart a course for recovery. This piece of work was unique in the sense that, while individual providers across the independent sector and NHS have done parts of this work, it pulled together a comprehensive sector-view of the impact of Covid, with a particular emphasis on the effect on throughput.

The introduction of protocols and guidance either adapted or added to existing processes in order to maintain patient and staff safety. For example, social distancing requirements reduce available space in waiting rooms leading to increased turnover time when patients are called in for their procedure. Other protocols affect procedures length itself; guidance related to aerosol-generating procedures (which includes extubation of patients after general anaesthetic) has a significant impact on the efficiency of surgical theatres, as it necessitates additional sterilisation and “fallow time” while the air settles before the next procedure can begin.

The first step in this analysis was researching and collating the relevant published material on guidelines and protocols from different bodies such as NICE, Royal College of Surgeons, Royal College of Radiologists, Royal College of Anaesthetists, among others. This exhaustive review of 20-30 documents, which often duplicated but were sometimes contradictory in their guidance, required an expert group of senior clinicians and operational managers to distil the guidance into six universally agreed protocols which affected operational effectiveness. It was a significant and necessary task to take the distilled protocols and translate them into drivers of delay, thereby quantifying how they increased procedure times and ultimately reduced throughput (see Exhibit 5).

As of July 2020, throughput of planned care in independent providers is estimated to have fallen to 57% of pre-Covid levels with a range of ~40% to ~70% across 20 archetypes of planned activity (see Exhibit 6). The worst affected archetypes tended to be complex activity, where the patient is under general anaesthetic and the procedure itself is aerosol-generating.

The roadmap to recovery: tackling the Covid-related disruptions

The lessons learnt by the independent sector on the operational effects of Covid, and early efforts to tackle the disruption, are the foundation of a structured roadmap which specifically targets the Covid-related drivers of inefficiency to chart the course for recovery. The independent sector is already on this course for recovery and is now achieving throughput of over 80% of pre-Covid levels. To fully mitigate the Covid delays and reach 100%, the roadmap utilises three levers (see Exhibit 8):

A. identify and agree best practice implementation of protocols

B. increase operational productivity and efficiency across 5 areas

C. shift mindsets and behaviours

These three levers are interdependent and mutually supportive. Achieving A underpins the delivery of B while C is a critical enabler that allows both A and B to reach their full potential.

A. identify best practice implementation of protocols

The objective of this first initiative is to take all published guidance and consolidate it into an industry agreed best practice that is both effective at maintaining patient and staff safety, while allowing a return to pre-Covid throughput levels. Where there is currently confusion and anxiety in how providers should implement guidance, there will be clarity and certainty of action. This lever requires the coordination of leading clinicians with the mandate to agree what best practice looks like. Operational leaders will have to be engaged in this process, to provide insight into how the best practice can be implemented with a minimal impact on operational effectiveness.

B. increase operational productivity and efficiency by addressing Covid protocols and their drivers of delay

• Capacity: maximise physical capacity to increase number of procedures carried out in a given time or complete procedures concurrently
• ‍Technology: utilise technology to treat patients in the most effective way that minimises demand on staff and physical capacity
• ‍Workforce: optimise workforce to increase available hours, fill critical positions and optimise productivity
• Scheduling: schedule procedure times to maximise throughput by minimising downtime and increasing parallel processing
• ‍Pathways: optimise pathways to reduce procedure lengths and increase parallel processing

C. shift mindsets and behaviours

In the effort to understand the impact of Covid, clinicians and operational managers highlighted shifting mindsets as the crucial enabler to realise the full potential of both A and B. The objective of this initiative is to understand the mindsets that are causing the delays and address them. The most critical mindset to tackle is the understandable but misplaced imposition of the strictest possible Covid protocols which, when taken to the extreme, do not actually add to patient safety. Overzealous application of protocols for individual patients directly leads to reduced throughput which, in turn, compromises the collective safety of all patients.

The roadmap to recovery: broadening the scope and driving efficiency to new highs

Tackling the protocol-related inefficiencies effectively may well take activity back to pre-Covid levels, but, due to the unprecedented challenge the country is facing, it will be necessary for NHS and the independent sector to broaden the scope of their improvement to achieve above 100% of pre-Covid levels. A reasonable target might be 120%, which would reduce the waiting list to pre-Covid levels of 4.5m patients over roughly a two-year period.

To achieve such radical improvement across a large footprint of providers will require addressing the more “traditional” sources of extracting value in planned care operations. This will include reducing theatre downtime, optimising procedure time, maximising use of available theatre time, optimising use of physical space, and most importantly, reducing variability across teams. These areas will have to be supported by shifting mindsets of teams right across hospitals and deploying technology to amplify the effect of individual initiatives.

The stakes for the patients of this country are exceptionally high. And the challenge for the NHS is like nothing else in its history, for three reasons:

• NHS leadership has outlined targets for providers to recover throughput to ~90% of pre-Covid levels by Winter. Because of the safety requirement to maintain distinct theatre capacity for planned Covid negative patients versus emergency patients, some hospitals are operating with 75% of their theatres for planned care activity. Reaching 90% of pre-Covid throughput overall will require efficiency of 120% in these remaining theatres (it will take 160% of pre-Covid efficiency in these theatres to reach the 120% total throughput required to begin reducing the backlog).
  
• Demand for emergency care is coming back. Both A&E attendances and admissions, which dipped 57% and 40% respectively during the initial Covid response period compared to the same time last year, have since been rising. Emergency admissions in August were only 10% lower than the same time last year (see Exhibit 9). Traditionally when NHS hospitals have faced emergency care pressures, including ambulances waiting to offload, overcrowded A&E departments, and patients being treated in corridors, planned care activity has suffered disruptions and cancellations.
  
• It is likely that these emergency trends will continue, and they may be compounded by a resurgence in Covid. Coupled with more regular winter pressures, the risks associated with a second wave of infection and increased admissions are currently substantial.
  

The NHS will have to achieve an unprecedented levelling up in efficiency, while working in an incredibly pressurised environment, if it is to meet the bar of this extraordinary demand.

The independent Sector will step up as much as it can to support the NHS and create value for the patient

These difficulties make it paramount that all areas of opportunity are explored and that the mutually supportive relationship between the independent sector and NHS is utilised as much as possible. Considering its relative size, the independent sector will always play a supporting role to the NHS, but it can and should excel in this role as it has done throughout the Covid challenge so far.

There are three areas where the independent sector is best placed to support the NHS and create value for the patient:

• Direct delivery of planned care activity to help the NHS reduce the “backlog” of patients. The independent sector is in strong position to assist because it:
• • Can deliver consistently at levels of operational efficiency above those achieved in the NHS
  • Leverages natural advantages of Covid free sites which reduce the risk of infection for patients and, in doing so, provide confidence to those patients reluctant to use NHS hospital services. Some patients are still reticent to access NHS hospitals for the care they require for fear of exposure to Covid
• Informal sharing of learnings from the recovery process to facilitate a step-change in efficiency not just in the independent sector but in the NHS as well
• Local partnerships between independent providers and the NHS which formalise the learning and sharing process to drive efficiencies in local health systems. These have been especially effective between diagnostic imaging providers and NHS sites, as they often share a geographical footprint

For these collaborative opportunities to be most effective, a transformation in the culture that has historically defined the NHS/independent sector relationship is necessary. The NHS will need to shift from viewing the independent sector as a pressure valve, to a source of efficiency and competitive advantage. In practical terms this would mean learning from pockets of excellence in operational efficiency, productivity, and effective management practices. It is important to note that this is by no means a one-way exchange of learning and there are also ample examples and future opportunity for the independent sector to embed best practice from the NHS in turn.

If effectively managed, this crisis is an opportunity for long-term improvement to the way planned care is delivered. It will be possible now to achieve a breakthrough in efficiency because we have had the unique opportunity to take everything apart, and then put it back together again.

The post-COVID window of opportunity for healthcare systems

The best way to view the Covid challenge is that it is opening a unique window of opportunity for a real transformation in healthcare service delivery to occur. Change of this magnitude and ambition would have been inconceivable even six months ago. This unprecedented short- term challenge can in fact represent a long-term opportunity as it provides the pressure and the impetus for all providers to achieve radical transformation.

In light of the scale of the challenge, there must  be a step change in the level of ambition across the healthcare system,  overcoming the walls that in the past had been blocking delivery: siloed working, resistance to change, etc. The experience of Covid has radically changed the way that people in healthcare delivery are working and the sense of working differently in the future is palpable. Now is the time to change and the whole of the healthcare system – public and independent – must step up to make sure that change is delivered for the people they serve.