A workable plan for elective care?
Research Manager and Head of Health
The words ‘winter pressures’ are burned into the eyelids of anyone working in the NHS. With flu induced hospitalisations quadrupling ahead of the new year, and more hospitals expecting to declare critical incidents in the coming days, it has been an unusually turbulent start to 2025.
But jumping from the world of emergency and into non urgent, elective care, these last few days have also brought a more optimistic tone for hospitals. On Monday, the Government released their Elective Reform Plan in their attempt to eliminate the seemingly immortal backlogs.
Even though some might question whether this target — to ensure 92 per cent of patients get treated within 18 weeks — is the right one, there is little dispute that a plan of action was necessary.
The context underlying the plan is crucial. The unavoidable fact of reducing elective backlogs is that they require substantial short term capacity injections, both in terms of staffing and equipment. This is not the case for all health care. Emergency care has seen huge capacity increases, which have not been matched by commensurately improved outcomes. In many cases reform, rather than greater capacity, is the answer. In the case of the elective backlog, we need both.
There are two capacity demands that must be met. First, we need enough capacity to meet the demand the NHS would be getting even without the backlogs, which is increasing by itself as demographic trends increase the volume and complexity of clinical demand. Without this capacity, backlogs will grow. Second, the NHS also needs significant additional capacity to deal with the extra demand that was artificially suppressed by the pandemic (though demand was already outstripping supply before then).
The Government’s proposals to meet these capacity demands are sensible but in no way revolutionary. Commentators are quick to compare every policy this Government introduces to New Labour. While there are some parallels, it is underestimated how much this plan is a continuation of the last government’s agenda, rather than a reheating of New Labour’s. Community Diagnostic Centres (CDCs) and surgical hubs — both effective innovations introduced under the last government — are key pillars of the plan. Rather than a radical refresh, it reiterates a well-trodden policy agenda.
Nevertheless, what it lacks in originality it makes up for in practicality. Continuing the trend of separating emergency and elective care through CDCs and surgical hubs is welcome — emergency care can be highly disruptive so ringfencing equipment and staff to relentlessly work through elective demand is logical. These ‘cold sites’ are well suited to high volume low complexity surgeries, such as cataract removal or hip replacements.
However, the question of whether this will be enough extra capacity is not clear. In 2023-24, only 20.2 per cent of high volume low complexity surgery was taking place on a cold site. Indeed the major delivery question with separating elective and emergency care is how to staff it. The Royal College of Radiologists found that 89 per cent of CDCs are staffed with existing trust employees and so rotating staff between the CDCs and hospitals might actually be diluting capacity in both settings. Given the acute need for both more capacity and higher productivity, it is perplexing that a resourcing strategy is largely absent in the plan.
A notable positive is some of the initial funding reform. Delivering outcomes in the NHS comes down to a crucial enabler: the right incentives. Paying trusts more for the delivery of specialities with high waiting lists — such as gynaecology — and introducing new tariffs to incentivise a shift to outpatients is welcome. Revamping how patients and the NHS manage their appointments using the (chronically underused) NHS App could also help to achieve a more efficient elective care pathway.
But as ever the glaring omission was, of course, on the question of budgets — how much money, for how long and to where. The budgets NHS leaders will have in place to deliver the levels of activity required have not been confirmed and the future of the Elective Recovery Fund is as yet undetermined. The Spending Review should clarify that, but that won’t be for another six months. Such an ambitious target, with an ambiguous funding trajectory, in the context of numerous ICSs and trusts running on a deficit, is not sustainable.
Ultimately this plan is not a radical reinvention of the policy landscape for elective care, but it is a step forward. Crucially, whether it is a sufficient condition for the delivery of such a bold target within five years — something that took New Labour nine years, with huge cash and staff injections — is uncertain.