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Recovering elective waits inclusively: where to start?


Can the NHS effectively combine the aims of clearing the elective backlog and tackling health inequalities? It’s a question that systems and providers have been faced with since NHS England requested that recovery in the wake of the pandemic is managed inclusively. Some may think these aims are at odds with one another, while others will champion their unification. In the first stage of a new research project about inclusive approaches to reducing the backlog, we have been looking at what we can learn from NHS boards about how this issue is playing out.

Clearing the elective backlog is a top priority for NHS providers. At the same time, we know that there are inequalities in how long some patients are waiting for treatment, including those from more deprived areas. How trusts and integrated care systems (ICSs) are interpreting and responding to the central directive to tackle the backlog inclusively will provide key insights into how current elective pressures are competing with – or, alternatively, could complement – the wider sector drive to reduce health inequalities.

The NHS was first asked to focus on restoring services inclusively in August 2020, with the policy evolving over time to include greater detail on elective waits. The most recent NHS operational planning guidance for 2022/23 emphasised the role of trust and integrated care boards (ICBs) in tackling inequalities in the backlog: they are asked to disaggregate their board performance reports by deprivation and ethnicity and to consider this analysis when designing and prioritising service delivery. As part of the first stage of this research, we reviewed the recent board papers of 13 acute providers and their corresponding ICBs to see how they were implementing this ask. The trusts were selected to include a range of waiting list sizes and growth rates, levels of deprivation and ethnic diversities within populations. Our analysis comes with caveats: not all discussions and plans are captured at board level, we only read a sample of papers, and this work may not appear in board papers if it has been delegated to sub-committees.

Most of the board papers we reviewed did not include performance reports broken down by ethnicity and deprivation as specified by the guidance. In fact, most papers did not explicitly reference the inclusive management of waiting lists at all. General, broad commitments to tackling health inequalities were frequent but lacked detail about how this would be delivered within elective recovery programmes. Several papers mentioned difficulties in collecting high-quality data, and we know data quality and availability has long been a barrier to analysis of health service datasets using ethnicity data. The most significant impact this policy could have is facilitating much-needed improvements in NHS data quality, most notably in ethnicity coding.

General, broad commitments to tackling health inequalities were frequent but lacked detail about how this would be delivered within elective recovery programmes.

We did identify a small number of initiatives, either underway or planned that aimed to specifically tackle inequalities in elective waiting lists, including:

  • analyses of outpatient ‘did not attend’ rates by patient ethnicity and deprivation

  • targeted outreach to patients more likely to not attend appointments

  • using digital tools to identify inequalities in waiting lists

  • regular monitoring of patients with a learning disability on lists

  • prioritising patients by socio-economic factors (in addition to clinical need and time waited).

We found more actions in providers’ board papers than ICBs’, with messaging on this policy and its implementation rarely aligned between providers and their corresponding ICB. This suggests that the role of ICSs in creating a system-wide approach may be less developed, particularly for those areas where partnership relationships are still being established.

The public are understandably concerned that they or a loved one could be moved down a list, resulting in an even longer wait.

Several trusts cited an intention to consult with the public to seek their views on how to tackle health inequalities. A recent public consultation in Coventry and Warwickshire sought to understand views on using different waiting list prioritisation criteria to reduce inequalities. This deliberative work found that participants supported addressing ethnicity and deprivation-related health inequalities, but did not think that waiting lists were the right place to do this work. The public are understandably concerned that they or a loved one could be moved down a list, resulting in an even longer wait. Public consultations also act as opportunity to reflect on the public’s awareness about how inequalities in elective care arise. How many of the public understand why someone with caring responsibilities may be more likely to miss an appointment, or acknowledge that some patients have fewer opportunities to articulate their needs or negotiate their preferences?

Several questions remain for this policy and its implementation, which appears to be in its infancy across systems – what approaches are different providers taking, how will trusts and ICSs be held to account, and will other priorities ultimately take precedence? It remains to be seen what effect recent political changes will have on the level of priority given to work to address health inequalities, with the upcoming operational planning guidance likely to provide the first indication of whether this issue will remain a significant focus in elective recovery efforts. If so, policymakers will have to find a delicate balance between specifying requirements to provide assurance and creating flexibility for providers to tailor initiatives to their populations’ needs.

This new research project by The King’s Fund that is being funded by The Health Foundation will explore in detail how acute providers, their corresponding ICSs and regional teams are making sense of this policy. The project will aim to inform future policy developments by identifying the key barriers and enablers to generating impact through meaningful, locally informed implementation.