The persistent menace of Covid-19 means hospitals up and down the country are being forced to remove beds and redesign buildings to keep patients safe as they restart routine services. But infection precautions mean only half the normal number of operations a day can be carried out.
More than one in six people in England could be waiting for NHS treatment by the autumn – the result of Covid-19 forcing hospitals to run at 60 per cent capacity as the threat reshapes healthcare services.
The Independent can reveal NHS England will extend its nationwide contract with private hospitals beyond June and into the summer. Health chiefs are in talks to come up with a longer-term deal that will see private healthcare companies integrated into the NHS like never before and providing up to 2 million NHS procedures a year.
Health secretary Matt Hancock has made clear he expects private hospitals will have a “critical role”.
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Experts and hospital leaders warned the impact of coronavirus will mean longer waits for treatment, higher costs for the taxpayer and a need to ration care to an extent normally seen only in poorer countries.
One hospital chief said: “The outer circle of what we provide is going to shrink.”
There was unanimous consent among more than a dozen health leaders that use of the private sector was going to have to become a cornerstone of any planned recovery for the NHS and could last for years.
Nigel Edwards, chief executive of the Nuffield Trust think-tank, said it was likely the NHS would experience an overall “relative decline” adding: “We are a country with high-income standards and high-income expectations, but we’ll be confronted with a capacity of something considerably less than we’ve been used to. That will create some very significant tensions.
“In 18 months’ time, people will be looking at the NHS and saying this isn’t quite what we’ve come to expect.”
‘There is always some pain’
For former police officer and army reservist, Steve Cassidy, the issue of huge waiting lists for NHS treatment is very personal.
Steve’s appointment to finalise plans for a replacement hip operation to treat osteoarthritis was cancelled in March due to coronavirus.
Now like millions of people, the 57-year-old from Poole in Dorset is forced to wait in pain, losing sleep and worrying when his ordeal will end. He has been told by the NHS it could be between three to six months before surgeries restart.
Steve, who is supported by the charity Versus Arthritis, takes around 16 tablets a day just to take the edge of his constant pain. He said: “It’s like an elephant has a stiletto-heeled shoe on and is standing on my hip. It’s only going to get worse. The wait has got to be cut. It’s too much pain to live with for such a length of time.”
He told The Independent: “There is always some pain there. The bottom line is if anyone said to you, you have to be like this for the rest of your life, I would say what is the point. It makes life a complete misery. Last week I was sat with my wife just crying because the pain was so bad.”
One orthopaedic surgeon in the Midlands said leaving patients waiting for operations like hip replacements was known to have an impact on their outcomes.
He said some patients could be left in a situation where their quality of life deteriorates to a position “worse than death”, adding: “If we delay surgery and you start from a worse position, although patients improve, they don’t improve as much as they would if it had been done earlier.”
He added delaying surgery also meant more bone erosion and damage to joints – meaning more costly and longer surgeries.
Robert Francis QC, chair of Healthwatch England, a statutory body which advocates for patients, said the NHS needed to include patients like Mr Cassidy in treatment decisions and planning. He said interim support needed to be offered so patients don’t feel “forgotten about”.
He told The Independent: “As a nation, we are very proud of our health and care services, and we have come to expect high standards as the norm. But the sheer size of the current backlog presents one of the biggest challenges in the history of the NHS and will undoubtedly impact on people’s experiences of care.
“For those struggling or in pain, longer waiting times cannot be seen as an inevitability. As a country we need to explore every option to get lists down, including continuing things that have been introduced during the crisis such as greater seven-day working and thinking how we might deploy the extra capacity provided by the Nightingale hospitals longer-term.”
Up to 10 million people left waiting
Since the start of the Covid-19 crisis, NHS hospitals have treated more than 95,000 patients with the deadly disease but it came at a huge cost. Freeing up thousands of hospital beds meant stopping almost all routine, or elective, surgery, outpatient appointments and referrals, many for patients who may have cancer and other life-altering conditions.
Only in recent weeks have health chiefs been given the green light to begin the recovery process, but no one believes it will be quick.
Heading into the crisis, the NHS was already struggling to cope with demand for surgery, with a waiting list of more than 4 million people. The target for treating patients within 18 weeks last achieved in March 2016.
Around 1.6 million patients join the waiting lists each month, meaning an extra 3 million may have been added after April and May. Add in the 10 days of lockdown at the end of March and the start of June and the waiting list could already be at 8 million.
With hospitals only just beginning to recover but still at reduced capacity, the waiting list will grow further in coming months and could rise as high as 10 million by the autumn.
Rob Findlay, director of demand and capacity planning company Gooroo, said he estimated the waiting list by the end of this month – just three months after the NHS took measures to focus on the Covid-19 epidemic – would be between 6.2 and 8.4 million.
He told The Independent: “This clearly is a very large number. In terms of waiting times, it is reasonable to assume during shutdown that waiting times are rising by one week, every week; at the end of March, the English national waiting time was 92 per cent of the waiting list at 26.5 weeks.”
He said he would estimate it could take the NHS three years or more to recover, assuming it can create the extra capacity needed to do that amount of surgeries.
“On a three-year timescale that would have the recovery continuing until 2024. There will be significant variation around the country too and some places will take longer.”
‘We can’t run like we have in the past’
Without an effective vaccine or rapid test that delivers results in under an hour, many hospitals are having to reconsider how they provide healthcare in a post-Covid world. The threat of the virus spreading within hospitals is not just a theoretical risk.
As early as March, the government’s Sage committee identified clusters of transmission within hospitals which then got worse in April, with minutes from one meeting saying: “There is significant transmission in hospitals. This may have been masking the decline in cases in the community.”
Sage was so concerned local hospitals were becoming hotspots for the virus it commissioned a study by health chiefs and new guidance for hospitals on infection control, including the design of buildings and the need to segregate patients, especially for elective surgery.
Patients who are about to have surgery are also especially vulnerable to the virus. A study in The Lancet looked at 1,128 patients across 24 countries and found more than half of patients who had surgery while infected with Covid-19 suffered lung complications, with 38 per cent later dying.
Hospital leaders told The Independent the risks were serious and the “new normal” for the NHS to keep patients safe meant removing beds and spending millions on physical building work to create separate Covid-free zones and buildings.
One medical director in the north of England said: “We must have biosecurity on our sites and biosafety for our patients and as a result of that there will be a decrease in capacity because we have to have the appropriate distance between beds and the zoning in hospitals. That is going to reduce our capacity.”
Several hospital chief executives said they were slimming down six-bed bays to four and taking out at least one bed from each four-bed bay. The hardest hit were NHS trusts in older buildings, with narrow corridors and a lack of single rooms to isolate patients.
One hospital chief said: “There is no question in anyone’s mind, current capacity will not deal with a post-Covid world. We can’t run like we have in the past. The numbers we are looking at is around 50 per cent theatre efficiency, we are looking at losing half our operating time.
“We are losing 15-20 per cent of our bed base as a consequence of Covid-19. Overall as a trust we are looking at 60 per cent of our pre-Covid capacity.”
Another hospital leader in the Midlands said his hospital was creating physical barriers between planned surgery areas and emergency wards, but this meant only four out of eight operating theatres were being used.
He added the delays caused by staff having to put on and take off protective clothing and extra cleaning would slow down work even more. He said: “That is going to restrict throughput through those four theatres by a further third, we think.”
All of this must be done while hospitals try to retain emergency capacity in the event of a second wave of the virus, which will lead to large numbers of patients needing intensive care.
Tough choices ahead
The reduction in beds, surgical capacity and the huge extra costs of coronavirus mean tough choices will have to be made on what the NHS will be able to offer in the future.
Nigel Edwards, from the Nuffield Trust, said the UK may have to get used to a standard of healthcare seen in less wealthy nations.
“If you’re a middle-income country, you start to make decisions about who does and doesn’t get access to treatment. There will probably be some tough choices about prioritisation, about where we put our money and resources. And it might well be that we have to look seriously at some of the thresholds we use for treatment.
“In terms of actual resources going in there’ll be more, but in terms of what we get out, I think there will be a significant productivity hit, and a very big backlog. The question will be: how sustainable is that? What will people feel about that?”
One NHS chief said their region was already looking to move to a defined budget for services.
He said: “This will mean we have a pot of cash that is X, we determine the care we can deliver is Y and this is what the public will get. You might call it rationing, you might call it a clearer definition of your true capacity, whatever it is, we were mentally starting to get attuned to that anyway.”
He added he was “very worried” about the public’s reaction: “We have an obsession in Britain, particularly in England, that the district general hospital is the answer to all of our ills. People like to complain about them. But when you try to change any elements of a service, all hell breaks down on you.
“We’re talking about longer waiting times for elective procedures and probably explicit rationing of certain work. That’s going to go down like a rat sandwich.”
The increased costs of dealing with coronavirus are also forcing NHS England to revisit the way it funds the service. Previously hospitals were paid for their activity with each operation having a cash value. But during the crisis, hospitals were moved to a block, or defined contract, which will come to an end in July.
With most hospitals unable to deliver the same levels of activity, many are warning they will be financially unsustainable.
NHS England is understood to be considering how to maintain a block contract approach, while also ensuring hospitals do not lose their grip on cost control. The health service is under sustained political scrutiny after receiving more than £20bn as part of a five-year plan plus billions in capital spending. There is nervousness in the NHS and in Whitehall that the NHS must deliver.
The government has repeatedly promised the NHS will get what it needs to combat the coronavirus but local hospital leaders believe a less restrictive funding settlement would free up hospitals to plan services better at a regional level.
Private sector’s critical role
All these difficulties point to a challenge for the health service that is likely to last for years, and risks overriding existing targets set for the NHS as part of its long-term plan, which was dismissed as “irrelevant now” by several senior hospital sources.
Nigel Edwards said: “You go down this list and all these things point in the wrong direction in terms of being able to get back to normal at any point in the foreseeable future.
“There will still be a major capacity constraint for years to come. We will need to expand the level of elective capacity even to catch up. And I suspect that probably means using the independent sector for at least the rest of this financial year. If not beyond.”
One doctor in central London said there were plans at his hospital to “bulk transfer” all diagnostics to the private sector, adding: “Colleagues have started looking through all of the patients we have delayed and trying to call in the ones we think are now urgent. We’ve been kicking the can down the road, and there is only so much can kicking you can do.”
Cliff Shearman, vice-president of the Royal College of Surgeons, said there were “enormous numbers of people waiting” for surgery, adding: “I can’t see us returning to as we were before. But nor would I say should we, because what we were doing before wasn’t working that well either. That’s why we had a waiting list.
“The college feels very strongly that some form of collaborative working with the independent sector is important, providing standards are assured.”
There are more than 270 private sector hospitals in England, delivering around 1.5 million NHS operations each year. At the start of the coronavirus outbreak, the NHS block booked the entire sector for use as surge capacity and for urgent operations that could not be delayed. It is thought the sector could add almost 500,000 more NHS operations a year as health chiefs try to stay on top of the waiting lists.
That move was not only a lifeline to the NHS but one for the private sector as well. One surgeon who works privately and in the NHS told The Independent: “Without the three-month contract during the crisis, private hospitals would have gone bankrupt as they had no business during the lockdown.”
He said part of the reason there had been such little activity in recent months was due to the low rates the NHS was paying compared with normal private practice. He said increasing private work was now inevitable, adding: “Waiting lists are going to be difficult and they were already pretty scary.”
That contract with private hospitals was due to end on 28 June but The Independent has learned NHS England will extend this into July while it continues talks with the industry on switching to a longer term “volume based” deal for NHS activity.
This could see mass use of private hospitals for diagnostic work. And already, some hospitals are talking to private providers to switch all their hip, knee and joint replacement surgery.
With a recession almost certain, the private sector is as keen as the NHS to sign a deal with insiders, saying it provides a level of security for the industry but also cements its integration with the health service.
Earlier this month, health secretary Matt Hancock told MPs: “The backlog has of course built up as we had to protect the NHS in the heat of the crisis. The independent sector has played a critical role in helping us get through the crisis and will play a critical role in future.
“That has put to bed any lingering, outdated arguments about a split between public and private in healthcare. What matters is the healthcare that people get. We could not have got through the crisis without the combined teamwork of the public and private sectors.”
However, this increased use of private hospitals could be a rallying call for anti-privatisation campaigners opposed to the use of the private sector.
Hospital chiefs told The Independent there was a risk these sentiments could destabilise local efforts to integrate services at a regional level. Anti-privatisation calls may also affect the creation of new regional integrated care systems which technically don’t exist as legal bodies but are playing an increasingly powerful role over the direction of local health services.
One hospital chief said: “People who scream privatisation when the NHS commissions block capacity from the private sector, it is just moronic. That discourse has to be challenged head-on with some pretty simple and easy to understand language.”
David Hare, chief executive of the Independent Health Providers Network, which represents private hospitals, said he expected more reliance on the sector to cope with the NHS treatment backlog as his organisation’s estimates also found waiting lists would reach 10 million later this year. He told The Independent: “We’ve run the numbers and that’s what we think it would be. We have to realise off the back of this awful crisis the health service will need the public and private sector to work together. If we don’t do that the public will be disadvantaged.
“Discussions are ongoing between the industry and NHS England on the future of private hospital utilisation. The arrangements for the next phase are likely to reflect a need to significantly increase capacity for routine activity rather than maintain buffer capacity.”
David Rowland, from the Centre for Health and the Public Interest, warned the NHS had been effectively subsiding the private sector for hospitals to stand empty during the crisis.
He said: “The potential solution to this is to rent the hospital from the private sector. At the moment what they are paying for is the operating costs of the hospital. If they use them to reduce waiting times the only way to do that is to shift large numbers of consultants and patients across to the private sector and they will be paying twice.”
A spokesperson for NHS England said the coronavirus had been “a once-in-a-century pandemic”, adding: “Now that the NHS has managed the first wave of this virus, there is clearly an important job to do to help people whose routine elective operation was postponed, which will involve permanent increases in staffing and bed capacity, as well as an ongoing partnership with independent providers.”
The Department of Health and Social Care said: “We have been clear that the NHS will get whatever funding it needs to respond to the coronavirus outbreak. On top of this, we are already providing the NHS with a record cash funding boost of £33.9bn extra by 2023-24.