The Covid-19 pandemic has impacted nearly every aspect of our daily lives since it was declared last year and access to healthcare is, unsurprisingly, no exception. NHS England figures have revealed that more than five million people are awaiting hospital treatment – the highest number since records began – with almost 400,000 of those having waited for surgery for longer than a year.

Among these figures are patients whose procedures were initially deemed non-urgent, but whose conditions will have since progressed in severity and their impact on day-to-day life.

More than two million elective surgeries were postponed or cancelled at the height of the pandemic and the strain the NHS has seen in the months since means clearing the colossal backlog will be no small feat. 

Last year, the NHS entered an unprecedented £2bn agreement to buy up almost the entire private healthcare capacity to treat patients during the crisis; that deal has since expired, but collaboration between the NHS and the private sector to tackle the backlog is far from over.

A new framework

From March, the NHS has been in a £10bn agreement known as the Increasing Capacity Framework (ICF) with over 80 private healthcare providers. Unlike the previous deal, which paid independent hospitals for access to their facilities, this new procurement framework will see the NHS pay hospitals according to the number of patients treated.

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David Hare, CEO of the Independent Healthcare Providers Network, says unlike the “highly unusual” deal made last year, the current arrangement resembles agreements often made between NHS and private hospitals in pre-Covid times.

“The current deal that is in place with the vast majority of independent hospitals in England is, in many ways, very familiar to the arrangements that were in place pre-pandemic,” Hare says, “insofar as providers are paid on the basis of a fee for service, the contracts are held locally with local NHS commissioning bodies and patients can choose to access independent sector hospitals for treatment.

“So, in effect, we are returning to some degree of normality.”

But it won’t be entirely the same as before. This time, for example, independent healthcare providers signed up to the ICF will have to go through a re-procurement six months into their contract – a bureaucratic process that wasn’t required under similar contracts signed prior to Covid-19.

The ICF enables the NHS to offload some of its patients to independent hospitals, but to achieve the mammoth task of clearing the surgical backlog, procedures must be allocated as efficiently as possible. Hare says the framework is “reasonably flexible” and allows providers to deliver the services that align with their specialties, like they had in pre-Covid procurement contracts.

“I think the big challenge, and it’s too early to say whether this will play through, is it’s clear the NHS will need an awful lot more activity done in the independent sector than pre-pandemic,” Hare says, “simply because of the size of the backlog and the number of patients that need treating.

“We are very much prepared to increase the activity levels that are available to the NHS, balanced, of course, alongside the need to maintain access for private patients, which too are growing in number.”

‘A long-term project’

The NHS has made headway in getting waiting patients seen – in May, the number of operations and other elective activity carried out had already climbed to 90% of pre-Covid levels – but experts predict it could take as long as five years for some trusts to work through their waiting lists. 

“This has to be seen as a long-term project,” Hare says. “We, therefore, expect the NHS to max out as much as it can on independent sector hospital and diagnostic capacity. But of course, we’re also seeing growing demand from those patients that are either exercising their private medical insurance policies or are choosing to self-fund their own care.”

Hare is optimistic that the independent sector can handle the demands of both paying patients and a severely backlogged NHS. The independent sector has lots of available capacity, he says, and there are “high levels of confidence” that the two priorities can be managed – but the ICF alone won’t be a panacea.

“We think there is real scope to deliver considerably more activity in the independent sector over the rest of this year, and indeed beyond,” Hare says, “but, in and of itself, that won’t be the sole solution to the problem.”

A blueprint for recovery

The ICF isn’t the only measure the NHS has taken to tackle the crisis. In May, the health service announced the introduction of elective accelerator sites, a £160m initiative aiming to reduce the surgical backlog and develop a “blueprint for elective recovery”. 

The sites will be trialled in 12 areas and at five specialist children’s hospitals, and each accelerator will receive a share of the funding “to implement and evaluate innovative ways to increase the number of elective operations they deliver”.

Efforts to be trialled in the initiative include a high-volume cataract service, one-stop testing facilities, increased access to specialist advice for GPs and pop-up clinics nearer to patients’ homes. The £160m funding will also go towards providing extra evening and weekend surgeries, new surgical hubs, ‘pre-hab’ for patients preparing for a procedure and more.

The ultimate goal of the initiative is to see NHS trusts exceed the levels of planned activity, such as diagnostic tests and surgical procedures, that were carried out before the Covid-19 crisis. 

Commenting in May, professor Neil Mortensen, president of the Royal College of Surgeons of England (RCS), said embedding the innovation and lessons learned during the pandemic is “key to the future sustainability of surgical services”.

Another deal?

When it comes to implementing changes, the RCS has its own ideas. In a report published in May, the RCS called on the government to implement the independent body’s ‘New Deal for Surgery’, which would mean committing an additional £1bn for surgery every year and introducing surgical hubs across the UK for specialties such as orthopaedics and oncology. Other recommendations listed in the RCS’ New Deal include an annual report setting out the Government’s response to the backlog, adopting a long-term aim to increase the number of hospital beds from 2.5 to 4.7 per 1,000 people, and building NHS capacity to reduce reliance on the independent sector in the event of future health crises.

RCS president Mortensen told Medical Technology the task of tackling the backlog is “gargantuan” and “will not be solved overnight”.

“A big part of the catch-up programme will also be the need to establish at least one surgical hub per integrated care system,” he says. “These hubs separate elective surgical services from emergency services and thereby allow operations to continue in Covid-secure facilities whether we face another wave of the pandemic, or the usual winter pressures. 

“In the long term, we need to invest in training doctors and nurses, as well as growing infrastructure such as beds and operating theatres, so that the NHS can never find itself in this awful position again. 

“In the meantime, the NHS may at times need to rely on the independent sector to provide the extra capacity it needs. It’s imperative, for the future of surgery, that trainee surgeons are given access to training opportunities in private hospitals, when NHS operations are moved there.”

An ‘unacceptable’ situation

At the heart of the matter is, of course, the millions of people across the UK waiting for treatment. The patients seeing the most severe delays are those in line for surgeries like knee and hip replacements – people with arthritis are “bearing the brunt of this crisis”, said Tracey Loftis, head of policy and public affairs at Versus Arthritis. 

The charity is calling for the government to implement the six-point support package it has developed to ensure those waiting for joint surgery receive the care and support they need in the meantime.

“It is critical that people with arthritis are not left struggling in pain with their lives put on hold,” Loftis said. “As longer waits lead to more severe joint damage and reduce the chance of future operations being successful, this issue becomes even more unacceptable.”

As the NHS’ accelerator initiatives and the RCS’ recommendations have made clear, dealing with the surgical backlog will take collaboration, innovation and adaptation in equal measures. With the waiting list predicted to take years to wade through, any measures that could alleviate the crisis must be implemented immediately.

“Although the majority of patients on our waiting lists aren’t in any immediate danger, the surgeries they are waiting for are undoubtedly life-changing – whether they be joint replacements that allow them to get on with work and day-to-day life, pain-free, or the insertion of cochlear implants that give the joy of hearing for the first time,” Mortensen says.

“They have waited patiently, and understandingly, through the pressures of the pandemic. Now we need to be able to get on with the job of providing their operations as quickly as possible.”