The biggest obstacle to NHS recovery plan

THERE was a certain irony this week that, on the day the Scottish Government unveiled a £1 billion NHS Recovery Plan, NHS Lanarkshire announced that it was cancelling the majority of its non-urgent elective surgery for the next couple of weeks.

Dr John Keaney, the health board’s acute medical director, said its staff were “struggling to cope” with the “relentless pressures, bed shortages and staff shortages due to sickness, stress and self-isolation”.

The five-year recovery plan also came on the day that Scotland reported a record 5,021 Covid infections in a single day and after emergency departments’ performance against the waiting time target had fallen to an all-time low.

In the week ending August 15, just 76 per cent of the 25,461 patients attending A&E were seen and subsequently discharged, transferred or admitted within four hours. Pre-pandemic, the worst turnaround rate was 77.8% – and that was in the first week of January 2018.

The summer months traditionally are the busiest for A&E departments, whose weekly average for August in the four years before 2020 was nearly 26,600 attendances.

But, under normal circumstances, few of those patients will require urgent admission to hospital and, if they do, bed availability is generally much better than it is in winter.

This August is different. In the week ending August 15, 239 patients spent at least 12 hours in A&E compared to a pre-pandemic weekly average of 31, and a pre-pandemic weekly average for January of 99.

Before Covid, many of these patients might have ended up stranded for hours on a trolley in the A&E corridor; now strict infection control means that they must remain in an A&E bed, while less urgent patients are left waiting in ambulances queued up outside, with knock-on delays for other 999 callers.

On top of all this, physical distancing means that total hospital capacity is reduced at a time when an increasing proportion of patients are presenting in primary care as well as A&E with chronic conditions, such as diabetes, which have deteriorated during the pandemic, or undiagnosed late-stage cancers. This has resulted in a surge in urgent, non-covid admissions which is leaving so many of those waiting for hip replacements and other planned procedures in limbo.

Emergency departments have always been a gauge for the NHS as a whole – simultaneously conveying the level of pressure within hospitals (staff and bed shortages, demand for diagnostic services such as CT scans and endoscopy) as well as the wider community.

Even before the pandemic, years of disinvestment in general practice had triggered a recruitment and retention crisis which had left patients in some areas struggling to get timely GP appointments and turning up at A&E instead; now a reduction in the number of face-to-face appointments which can be safely provided without risking an outbreak of Covid in the waiting room is exacerbating that problem, even as the total number of consultations general practitioners are actually providing (by telephone, video, etc) has ballooned well beyond pre-pandemic levels in most surgeries.

On this, the recovery plan states only that it will “urgently seek to fully restore face to face consultations in GP surgeries”, adding that Public Health Scotland will “imminently publish updated guidance for primary care settings covering key issues such as physical distancing requirements, access for patients and infection prevention control”.

Given spiralling coronavirus rates, evidence of waning vaccine immunity, and the fact that the Delta variant increases the chances of even fully vaccinated individuals contracting and spreading the virus, this will be challenging. The plan also states that Scotland is “on track” to increase the GP workforce by 800 by 2026, but that depends on how you frame it.

By headcount, the GP workforce has grown from 4,918 in 2017 – when this pledge was first made – to 5,134 in 2020. But that misses the impact of the growing percentage of GPS working part-time.

Counted as “whole-time equivalent”, the GP workforce has been in decline: down by around 160, to 3,575, between 2013 and 2017, the most recent year for which a WTE figure is available.

Audit Scotland, who warned of the trend in its August 2019 workforce report, noted that GPS in their 50s were more likely to be working full-time, while those aged 25 to 49 tended to be doing between four and seven sessions per week (full-time working is at least eight).

This pattern, said Audit Scotland, was “likely to mean that for every GP who retires more than one will need to be trained and recruited to replace them”. Given that one third of Scotland’s GPS are in their 50s, this retirement timebomb poses a very serious problem – particularly with medical early retirements expected to surge post-covid.

The recovery plan also outlines a vision of easing workload pressure on GPS by bolstering practices with community nurses, pharmacists, and mental health links workers, but that dates from the 2018 Scottish GP contract and, even before Covid, health boards (who will be responsible for employing these staff even if they are based in GP practices) were failing to supply them in the numbers required, either because they simply didn’t exist or because deploying them into primary care would leave a shortfall elsewhere.

Most of the recovery plan’s goals will rely on manpower – from the promised 55,000 extra (compared to pre-pandemic levels) inpatient and day-case procedures by 2026, to the network of National Treatment Centres delivering orthopaedics and other elective surgery.

Procuring additional CT pods, mobile MRI scanners and endoscopy equipment will not achieve the promised 90,000 extra diagnostic procedures unless we have the staff to operate them – and even before Covid diagnostic pathways were buckling under staffing shortages.

As Andy Glyde, of Cancer Research UK in Scotland, noted: “What’s important now is the detail of how this recovery plan will be delivered.”

Restoring pre-pandemic service levels will be a challenge given the large number of GPS working part time and the knock-on effect this has on hospitals, writes Helen Mcardle