Waiting for care arises from the mismatch between the need for care, and the capacity of NHS services to meet those needs and can lead to adverse outcomes.
The report from the Wales Centre for Public Policy highlights how the time spent waiting for referral-to-treatment (RTT) has been increasing since before the pandemic, which further exacerbated the underlying trend, a pattern repeated in other parts of the UK.
The report suggests practical policy action that could help to adapt the way services are organised and delivered in the short to medium term. However, the aim should be to achieve longer-term sustainable change to services rather than only doing ‘more of the same’ in a better way.
In the Parliamentary Review of Health and Social Care (2018) we noted that the pressure for increased investment in health and social care will continue, driven by factors such as the general health of the population, inequalities, workforce shortages, and the rapid increase in new treatments.
Recognising that resources will always be scarce, we advised that a key aim should be ‘to maximise the value of care and by being more efficient to enable resources to be directed to the areas that have a bigger impact on health and wellbeing’.
In response, the Welsh Government set an ambitious strategy to implement change across the whole system of care, with the aim of being more effective, efficient, and equitable (A Healthier Wales). The strategy aims to reduce need for care through prevention and early intervention and to provide seamless, improved services supported by optimal and system-wide use of technology. Publication of the strategy was soon followed by the enormous challenge of the pandemic.
The NHS in Wales responded to the pandemic with energy and innovation. The NHS Confederation report Addressing the planned care backlog (2022) illustrates how those lessons can help to meet waiting time concerns. Though, realistically, the energy to innovate requires sufficient staffing levels and some personal recovery time for staff after the pressures of the pandemic.
So, what can be done to meet what seems to be an insurmountable challenge?
The next step in bringing the strategy to life, post pandemic, is firstly – a realistic assessment of the capacity needed to reduce the waiting time to a level that optimises outcome and experience and incorporates the longer-term level of demand. For example, each specialist area of care provides for different diseases and future levels of need can be anticipated and planned for, such as cataract surgery, recognising that some patients have multiple conditions.
Crucially, this will guide the second issue. A long-term workforce plan for health and social care is vital which includes sufficient capacity to provide prevention and care services in the community as well as specialist services. Training in new skills and use of technology such as robot delivered surgery is important to support new working practices.
Thirdly, the organisation of care needs a re-think from the end users’ perspective. Whilst centres of excellence and surgical hubs can improve efficiency and help with staffing, they need to be designed with service users to enhance their experience.
Increasingly, patients have multiple chronic conditions and can find themselves attending a range of diagnostic and treatment services with little co-ordination. Solutions can be found but need to be co-designed and be supported by a willingness to change working practices. Building-in pre-treatment preventative approaches and strong post treatment rehabilitation is also essential to achieve the best outcomes.
Wales is a pioneer in developing ‘value-based healthcare’ which helps to focus on meeting the goals of patients and to manage expectations throughout their care or treatment. Improving how patients are involved in decision making, using the best evidence, avoiding any unnecessary variation in care, and becoming more creative to determine where the resources are best spent for improved patient outcomes. This should be centre stage in the future delivery of services, supported by data and information to guide decisions both at a patient level and service level.
The WCPP report cautions about a simplistic approach to performance management of waiting times. Success in truly transforming services and delivering A Healthier Wales requires a way of measuring progress that supports the delivery of long-term goals whilst showing the public and politicians that improvements in waiting times are happening in the short-term.
Patients want ‘timely care’, and staff want ‘time to care’. This is important for high quality outcomes and good patient experience. Urgent care should be urgent; access to diagnostic tests simple and well-coordinated; time available for effective shared decision making on treatment options; time for pre-operative preparation where needed, and time for well-organised long term disease management delivered with patient informed follow up.
The challenge is substantial. The new NHS Wales Executive has an opportunity to re-set how progress will be measured to ensure the long-term strategy is delivered as well as ensuring that the public can rely on urgent and planned care that provides improved experience and outcomes. This is not going to be easy, but it is essential for the future of the health and care system.