The elective care conundrum - can digital innovation help?

Karina Malhotra from Acumentice explores how digital tech and data could help address the NHS elective care backlog in 2021 and beyond.

The repercussions of the COVID-19 pandemic are going to take a considerable time to repair and nowhere is this more pertinent than in NHS elective care.

The impact on elective care has been considerable. Reports have shown that the number of people waiting more than a year for an operation has reached its highest level since 2008. According to NHS figures, in September 2020 139,545 patients in England had been waiting more than 12 months for surgery such as a hip and knee replacement or cataract removals. These waits have worsened with the winter period and some hospitals are already cancelling planned operations. Under the NHS constitution, everyone needing non-urgent treatment should get it within 18 weeks. This has posed two challenges – clearing the existing and growing backlog and instigating better systems and processes in doing so to prevent the same problem repeating in the future.

Problems pre-pandemic

While extended waiting times have sometimes been pitched as a problem created by COVID, but that is only partially true. Even before the pandemic, there were around 4.4m people on the NHS waiting list and although the majority – around 80% – of patients were treated within the 18 week constitution, it had been falling short of the 92% target set by the government for some time.

There are many factors at play driving this. We’ve seen extreme seasonal cycles of weather for several years now, which has upped demand for all services like ambulance, A&E and mental health care. Services used, in some regard, by pretty much every societal section. This has been compounded with the looming spectre of Brexit, which has meant the NHS lost some of its valuable workforce from overseas. Fast forward to March 2020 and the vast majority of elective activity was suspended due to COVID, massively adding to an existing backlog.

While the pandemic exacerbated historical issues, it also underlined that NHS can respond to a crisis and isn’t static, as is the widely-held perception. In moving into Phase III, it was asked to reach 80% of previous activity levels by the end of September, and in some areas they exceeded those targets.

The bluntness of targets

The answer to the capacity issue has, historically, been to increase efficiency and throughput – more people, smaller space, shorter time. Of course, in a world of social distancing and infection prevention and control, we’re now doing exactly the opposite. This, combined with the fact that existing metrics and processes for monitoring elective care performance may no longer be fit for purpose means a new approach is required.

Reverting to type is not an option and both clinicians and healthcare providers must find ways of treating those patients at most risk of harm in sufficient numbers to make a difference without simply working down a checklist to hit a target. It’s something the Royal College of Surgeons has called for – to not look at targets but look at the patients and what they need as individuals. As an example, Professor Catherine Urch has taken this approach and enhanced it at Imperial NHS Trust to include a measure for retrospective and prospective harm that may arise as a result of awaiting time to guide the decision further.

The key principle being that there’s huge variation between patients that need to be seen very quickly versus those that can wait and that the healthcare sector as a whole has to be mature and realistic about managing the huge numbers of diagnostics interventions, outpatients and treatments. The culmination of which is a very different lens to look at the clinical picture. It would mean not trying to meet a generic population within a given time period but instead, match the individual patient need against a population-driven set of priorities.

Critical to the success of this approach will be to engage clinicians in what is traditionally perceived to be an administrative function. We must enable them to bring their expertise and knowledge of their patient to the table, and allow them greater jurisdiction over the movement of patients rather than a next-cab-off-the-rank scenario. We have to be focusing on using our limited resources for the maximum value for those individual patients and a more clinically driven approach to doing that can only be a good thing.

Dealing in data quality

Thankfully, the NHS has proven itself to be an incredible innovator. We’ve seen more collaboration and adoption of new tools and technologies than ever before. That said, one area that remains ripe for disruption isn’t the waiting list process itself, but the quality of data on it. These lists contain thousands of names and if some of those are inaccurate or no longer required, it places much greater significance on the coveted appointment slots for the patients that genuinely need them.

However, unlike sweeping changes to attitudes and the core process of prioritising patients, improving data quality by using digital tools such that the manual work is reduced is something of a no-brainer. There are many examples where this is happening already. For instance, our partners at Imperial are using a ‘smart’ software (Qubit) to automate data quality correction and validation saving 35,000 manual hours of work annually. It is also worth noting that the clinical prioritisation and review process that we've supported implementation of at Imperial has seen an improvement in clinical engagement, which has resulted in improved data quality on waiting lists. Clinicians can decide what's important for their patients, and how long they should wait whilst addressing any inaccurate waiting list entries of patients not requiring treatment, leading to a 10% to 15% improvement in waiting list data quality.

All of these innovations are key because losing patients in the system or increasing the number of incorrect entries on the waiting list are the worst thing that could happen at this time. The balancing item is ensuring we have full-scale engagement with the patients – the people who ultimately pay for and are the beneficiaries of the services that we provide.

Capitalising on the rest opportunity

There is no doubt COVID has brought major challenges to the NHS but it has simultaneously exposed valuable learnings and it is critical we use the reset opportunity that has been given to us. It is clear that change is needed and we have to do things more efficiently, more effectively and more innovatively because even if we combine capacity in the NHS and independent sector, we still don't have the capacity to achieve the current targets.

The last 12 months have highlighted that we've got to have transparent and honest relationships with the people that we are actually here to serve. This has to be the bedrock of a future where lengthy elective care waiting lists are a thing of the past.

About the author

Acumentice founder Karina Malhotra is a former NHS director and senior leader, with extensive experience and subject matter expertise in all aspects of elective care management.  She has provided expert advisory support to executive teams at some of the UK’s largest Trusts. Karina founded Acumentice in 2014, with a view to share this expertise through the development of clear and sustainable methodologies and frameworks.