A complex pattern of new partnerships
The policy direction within the health and care sector has strongly encouraged health and care organisations to work together for the benefit of patients, and their own staff, for several years. This spirit of collaboration has been accelerated by the experience of the pandemic as organisations sought mutual aid, and rapidly developed new pathways and innovations.
The sector is not homogeneous, and these partnerships will take many forms, often blurring traditional boundaries, and incorporating a complex patchwork of general practice, PCNs, large scale primary care providers, trusts and other partners. NHS leaders in large-scale primary care organisations and within trusts all tell us, however, that new partnerships will be key in delivering the aims of the NHS long term plan, in improving shared understanding of data to reduce health inequalities and support population health management approaches, in driving digital transformation and improving care pathways, and in supporting patients and staff alike as we recover the care backlog.
Pressures across the system
We know that providers' achievements during the pandemic were significant: primary care pivoted successfully to digital and online delivery alongside maintaining critical face-to-face appointments and trusts continued to deliver urgent and emergency services and urgent cancer care, with renewed focus on elective treatment since the second peak of the pandemic. However, despite the best efforts of the NHS’ committed staff, there is now a need to sustain and accelerate the drive to recover waiting times and address a significant backlog of patients whose care has been delayed – an initiative helpfully supported by the ERF provided by NHS England and NHS Improvement and supported by the learning from a number of accelerator sites.
By May 2021, there were 5.3 million people waiting to begin hospital treatment – the highest figure since records began in August 2007 – and a core priority for colleagues across the NHS, as for government. Too many patients are also still waiting for 52 weeks or more for their care, although the number waiting this length of time decreased for the second consecutive month at the time of writing in July 2021.
Trusts have thus far outstripped national targets to recover planned care and reduce waiting times for elective services. This achievement reflects the commitment of NHS staff within trusts and primary care to deliver for their patient populations. However, the NHS faces a challenge ahead to sustain this momentum as restrictions on social interaction are eased and community infection rates inevitably rise leaving greater numbers of NHS staff in self isolation. The ERF is also only available to acute trusts for certain procedures and cannot be accessed by community or mental health providers.
While political attention often focuses on elective care, demand is rising for services across the system, creating a cumulative pressure on staff, and new challenges for primary and secondary care partners as they seek to support more patients in different ways, within a constrained funding envelope. As demand for urgent and emergency care rises, the risk of elective procedures being delayed and cancelled inevitably rises.
The following summary provides an overview of key demand pressures which will place pressure on providers' joint work to reduce the wait times for certain procedures:
- Activity continues to rise across the urgent and emergency care pathway placing pressure on GP out of hours services, NHS 111 and ambulance services which are facing unprecedented levels of demand for this time of year. For example, category one incidents (those requiring immediate intervention and resuscitation) are up by 8.1% on last month and by 27% from the same point of the year, two years ago. Trusts and their partners in primary care will need to balance the need to respond to urgent demand, with their efforts to reduce waiting times for planned care.
- Diagnostic activity increased in May 2021 but remains below pre-pandemic levels. The diagnostic waiting list has increased by 3.4% to 1.31 million since the previous month, with 22.3% of people waiting six weeks or more for a test in May – missing the national target that no more than 1% of patients should wait more than six weeks. Reassurance and support from general practice, underpinned by good communications between specialists and primary care colleagues, will be key for patients awaiting a diagnosis or seeking clarity on next steps in their treatment plan.
- Cancer activity is now slightly above pre-pandemic levels, however, there is still a need to meet existing national targets including for urgent GP referrals seen within two weeks and waiting 62 days for treatment from an urgent GP referral.
- Pressures on mental health services continue to rise, with the highest number of people (1.41 million) in contact with mental health services since records began, 8.8% more people in contact compared to a year ago. Demand for child and adolescent mental health services (CAMHS) has increased sharply, exacerbated by isolation and other factors related to the experience of the pandemic. While NHS England and NHS Improvement is seeking to increase funding for mental health services, and for children's services, there is no doubt that the increase in complexity and overall demand is generating new challenges for primary care and for trusts.
Impact on patient experience and outcomes
Behind these figures are difficult experiences for individuals and their families. As patients seek clarity on their treatment plan, there is an increased risk of individuals being 'bounced' back and forth between primary and secondary care, with no clear pathway for treatment and having to live with pain and worry. We also know that not all patients with long term conditions waiting for care or clarity on next steps, will be captured within the definition of the national waiting time standards yet they are very likely to make regular contact with general practice to seek advice. There is a time dividend in primary care to be gained from much better access to queueing information for patients directly from their secondary care provider.
This does not just mean poor patient experience. In those who are managing long term conditions – estimated to be more than 15 million people in England – delays can lead to exacerbations and harms that may otherwise have been avoided. In cancer care, much has rightly already been written about the impact of delayed diagnoses and treatment during the pandemic, despite the NHS sustaining urgent cancer care. The impact of the pandemic on mental health and wellbeing is becoming clearer, with sharp rises in demand for CAMHS services, and a need to support the wellbeing of carers rising to the fore.
Impact on staff providing care
The NHS has just celebrated its 73 birthday. At no moment have the challenges faced by staff in all disciplines been greater. Recognising the sacrifice, exhaustion, frustration and success felt by leaders and their teams is vital. In a recent NHS Providers survey, 48% of trust leaders said they had seen evidence of staff already leaving their organisation due to early retirement, COVID-19 burnout, or other effects from working in the pandemic. Three quarters of trust leaders told us that they are concerned that recovery will be disrupted by further COVID-19 waves in winter, with 78% extremely worried about winter itself. These anxieties are of course also reflected across primary care providers.
Although improved partnership working cannot alleviate all these pressures, leaders from large scale primary care, and secondary care providers told us that new partnerships helped make best use of limited staff capacity, and that it helped staff to develop common aims and to develop their networks of mutual support.