Why did we do this work?
In the aftermath of the first wave of the Covid-19 pandemic, the NHS decided to think differently about its approach to recovering elective services by taking an inclusive approach. This was part of a general push to ‘build back better’ – a feeling that the pandemic could be a pivot point after which public services might start to make real progress in addressing some of the fundamental inequalities in society, which had been laid bare by the unequal impact of Covid-19 on different population groups.
NHS England asked trusts and systems to work on inclusive recovery by looking for inequalities on their waiting lists by deprivation and ethnicity, and then prioritising ‘service delivery’ by taking this into account. This was a fundamental change in the way the NHS was asked to manage waiting lists, applying an inclusive approach to a core operational process. However, the policy was broad, and left local areas to define their approach. The King’s Fund has previously said that progress tackling health inequalities hinges on the NHS making this work part of its business as usual, rather than an add-on. We wanted to understand what happened when policy‑makers tried to do exactly that.
What did we do?
Three years after it was first announced, we wanted to explore how the policy for NHS organisations to take an inclusive approach to tackling their elective care backlogs was being interpreted and implemented in three case study sites.
The research included:
- a scoping phase that explored what is already known about work to take an inclusive approach to tackling the elective care backlog through an analysis of trust and ICB board papers, relevant literature and national waiting times data
- three qualitative case studies of the progress made in implementing the policy in NHS trusts (two acute and one specialist) and their main ICBs. We also interviewed a range of other people about using AI to target and re-prioritise elective care (39 interviews in all, that took place between December 2022 and June 2023)
- a workshop with a range of national and local stakeholders to discuss our findings.
What did we find?
What are inequalities on waiting lists and why do they happen?
There are structural, economic and social factors that can lead to inequalities on elective waiting lists. Our analysis of national waiting times data found that in August 2022, people who lived in the most deprived parts of England were twice (2.1 times) as likely to wait more than a year for elective treatment as people who lived in the most affluent areas. People with the same clinical needs might experience differences in the length of time they wait or the impact of waiting on their health and quality of life because:
- appointments can be difficult to attend – for example, because someone cannot take time off work or does not have access to a car or public transport
- the NHS can be difficult to navigate – for example, some people find it harder than others to articulate their health concern and advocate for treatment
- people reach the waiting list in different health states and deteriorate at different rates – for example, there is evidence that people from more deprived areas are more likely to have multiple health conditions, deteriorate more quickly, develop complications while they wait and experience worse health outcomes
- individual circumstances affect whether a patient’s condition affects their ability to work or fulfil caring responsibilities.
This means that an approach to managing waiting lists that is based solely on treating people with similar clinical needs equally risks missing other factors that might widen inequalities. These causes of inequalities are likely to coalesce in different ways and to different degrees in different parts of England and for different specialties – meaning any action needs to be tailored locally.
What are local trusts and ICBs doing to address inequalities on waiting lists?
There are examples of successful local initiatives to tackle inequalities on waiting lists including:
- targeted work to reduce rates of missed appointments (‘did not attends’ or DNAs) – for example, at the Royal Free London NHS Foundation Trust or University Hospitals of Leicester NHS Trust
- targeted support that helps maintain or improve people’s health while on waiting lists (prehabilitation) – for example, at Cheshire and Merseyside ICB and Lancashire and South Cumbria ICB
- the use of AI to prioritise people on waiting lists – for example, at University Hospitals Coventry and Warwickshire NHS Trust
However, despite the stated policy and pockets of innovation, our research did not find evidence that the NHS is systematically taking an inclusive approach to tackling the elective care backlog. This was because of issues at national, system and trust levels, that include:
- a lack of clarity on the case for change, action to be taken and what success looks like
- operational issues such as poor data and analytical capability
- fundamental cultural challenges because of different views among NHS staff about what constitutes a fair approach to tackling the backlog, especially to reprioritising waiting lists.
Furthermore, taking an inclusive approach is still not part of the performance management and accountability structures established by NHS England to manage other aspects of elective recovery. Ministers and national NHS leaders’ attention has been on reducing the overall size of the elective backlog and the headline length of waiting times, which means NHS staff energies have been focused on this task.
Waiting lists are one place where the causes, experiences and consequences of health inequalities coalesce. If the NHS is serious about addressing health inequalities, it needs to address inequalities on waiting lists as part of that. The policy is hitting a system that is already struggling to stay afloat because of significant financial and operational pressures. But for trusts and integrated care systems (ICSs), our research shows that rather than needing to do something completely new, making progress is partly about doing the work they already have in train in a more targeted way, and using data and community insight to work out what that targeting should look like.
If the NHS is to play a meaningful role in tackling inequalities on waiting lists then that work needs to become a core part of effective waiting list management now, rather than the system not being able to do so until current pressures subside. To overcome inertia and a lack of progress, leaders at all levels must support staff who are trying to do this work – recognising the value of their actions to tackle inequalities alongside work to tackle long waits. In the long term these approaches contribute to a more equitable health system and healthier communities.
The inclusion of work to tackle health inequalities in core functions is something that needs to happen across the NHS and our research illustrates the challenge of doing this. We have identified three areas that bridge the gap between current policy and practice and the aspirations to deliver elective recovery and to address health inequalities. These are the areas on which we believe national, regional, system and organisation leaders need to work to accelerate progress with taking an inclusive approach to reducing the backlog.
Figure 1: Recommendations for bringing work on health inequalities and elective recovery together
Progress will be based on joint working between a range of organisations across the NHS, wider public sector and voluntary sector. Here we set out recommendations for NHS England, ICSs and trusts. ICSs include the ICB and the integrated care partnership (ICP) that both have an interest, duty and role to play in reducing inequalities.
Make the case for change
- put an inclusive approach at the centre of elective recovery plans
- develop a vision that emphasises the importance of understanding the local population’s experience of waiting times and explains why deprivation and ethnicity are relevant factors to consider
- engage the public in this vision.
- set a local vision for inclusive elective recovery with clear goals
- engage clinicians, operational leads and communities in the vision.
- work to engage the board, clinicians, operational leads and communities in a vision for inclusive recovery using local data to make the case for change.
- develop and share guidance, tools and examples including an ethnical framework to support conversations with the public
- make long-term sustainable funding available.
- develop a quality data source that enables inequalities to be explored at system, place, trust and specialty level
- bring together key stakeholders to discuss the data
- identify and act on inequalities in use of NHS-funded independent sector care
- share best practice.
- highlight specific actions that staff can take to support change – for example approaches to data analysis, engaging communities, targeted work to reduce DNAs and prehabilitation
- work with local communities to understand why inequalities exist and what would work to address them.
Hold to account
- embed health inequalities into core assessments and performance management processes for elective recovery in their national and regional team.
- track inequalities on waiting lists across their system as part of elective recovery monitoring and work with the ICP to consider what action can be taken at system level.
- include performance measures relating to inequalities in their operational performance dashboards.