“The provision of workforce and capacity has become one of the most challenging issues for healthcare. With the National Health Service experiencing one of the worst A&E waiting times in recent years and significant referral to treatment access standards, insourcing has become a really valuable delivery pipeline for leaderships teams across the sector.”

– Orlando Agrippa, Draper & Dash Healthcare

By Nicola Ellis-Webb, ICS Insourcing

In recent months, we have witnessed considerable national debate around NHS waiting lists and the suggested changes to the access standards, including RTT. As the system struggles to meet increasing demands for both elective and emergency services, it is good, right and proper that we determine and focus on our priorities. Professor Stephen Powis in his interim report, has put forward a plan that does just that. He proposes that ‘greater emphasis be given to standards that help improve clinical quality and outcomes – such as earlier diagnosis of cancer and faster assessment and treatment for major emergencies such as heart attacks, stroke and sepsis’. It would be idle to spend any time espousing or rebutting the appropriateness of these priorities as they are rarely contentious. Nevertheless, it is also important that we continue to shine a light on elective services particularly on any opportunities for improvement.

Considerations on the various drivers that cause an increase in the size of the RTT backlog are outside of the scope of this article. Instead, the focus will be on practical solutions for clearing the current, seemingly insurmountable backlog. The total number of people waiting to start consultant-led elective treatment remained above 4.3 million in February 2019 which represented an increase of 10% over the preceding 12 months. Still, the expectation is that all providers will improve their waiting list position during 2019/20 and that their capacity plans will demonstrate how they will increase elective treatment so that the waiting list number will decrease. The road to recovery will not be without challenges and a whole system approach is necessary to ensure that high-impact technological advancements are widely utilised to maximum effect. For example, clinical pathway redesign, redefining of access points and digital booking options provide promising solutions. These options will enable providers to improve utilisation and to realise extra capacity by incorporating flexible follow up options such as virtual and telephone clinics.

It is hoped that the above, coupled with more effective scheduling of appointments and more efficient working practices should make a much-needed dent in the overall RTT number. However, as NHS Improvement advised in late 2018, it is time to seek help from the private sector for practical solutions to address the backlog.

The private sector provides several options for RTT relief. From the traditional choose and book option that enables CCGs to divert patients from already stretched NHS Trusts, to the outsourcing of 52-week waiters and other complex cases to private hospitals and more recently, the widely accepted option of insourcing. Insourcing enables trusts to increase their internal capacity so that they improve access to outpatient, diagnostic and surgical services.

Insourcing too has its challenges as services must integrate seamlessly into local workflows with very little disruptive impact on trust administrative, clinical and operational teams. Governance arrangements must keep patients safe and guarantee each a positive experience. Crucially, insourcing must be cost-effective while offering flexible commercial options to suit local income arrangements, whether block contract, PBR or a mixture of both.

What then are the arguments against insourcing? Certainly, if good governance and service integration cannot be established then insourcing may not be appropriate. Secondly, insourcing services have limited scope because the clinical teams are transient, typically available only at the weekends. Consequently, only day case or 23-hour cases are accepted. Inpatient services can usually be accommodated with local clinician engagement but necessarily require exceptional implementation planning and much deeper collaboration between operational teams. The main limitation of insourcing is therefore the exclusion of complex cases which is often the main pressure point for NHS providers. Lastly, if steps aren’t taken to maximise utilisation then unmanaged DNA/cancellation rates could mean unnecessary spend but it could be argued that this is also the case with local waiting list initiatives as well.

What are the benefits of insourcing?

Insourcing services properly developed and delivered does have huge benefits for managing NHS backlogs, namely:

  • Increase patient throughput because of innovative workflows
  • Access to specialist consultants and nursing workforce to tackle diagnostic, 2WW and surveillance cases
  • Increase in patient satisfaction as they can be seen within their local trusts 7-days a week
  • Improved RTT and diagnostic performance
  • Local teams have better oversight of service governance
  • As services are kept in-house, this builds resilience into local teams as the risk of burn-out in delivering a 7-day service is minimised

Altogether, the private sector has continued to develop high-impact products and services that collectively provide support to NHS organisations that are dealing with RTT challenges. We have accepted, with enthusiasm, that the limited financial resources are being targeted, firstly at managing priority services so that we can all have access to urgent and cancer care services if needed. Still, we can retain some enthusiasm for the future of elective services even if the impact of the proposed changes remains unknown.

As we await the results from the pilot sites that will trial the new RTT standards, we can take comfort in several things. Namely:

  • Fifty-two (52) week breaches will happen much less
  • At 26 weeks, if you are still waiting then you will be contacted and offered other provider options
  • Technology will be used to drive efficiencies and improve our experience with NHS services.

As care becomes ever more integrated between the NHS and private sector organisations, we will hopefully see an acceleration in knowledge and innovation that results in system-wide changes and improvements in how we manage elective services. We watch with optimism.

ICS insourcing along with Stalis will be at this year’s RTT and Data Assurance Summit hosted by Draper & Dash. To join the conversation regarding insourcing and the imminent RTT changes and the quality of healthcare data, please register your interest to attend here.

Please click here to download a complimentary RTT report for your Trust