Elective care – here are the lessons the NHS can learn for this winter!

Shortly after joining the company in August 2023, our Principal Consultant, Michael Watson , took on his first assignment at a medium-sized trust in the south of England. His role was to help transform their elective care services – and crucially, reduce waiting times – by implementing practical, commonsense steps.

Here, he outlines the challenges we faced, how we overcame them, and what the NHS can learn for this coming winter to be ready for the inevitable pressures and improve performance.

Throughout my career, I have provided improvement support in NHS trusts across England. Shortly after leaving NHS England to join Acumentice, then, it was no great shock to the system to find myself back in a hospital environment.

This particular trust in the south of England had recently made changes to its Referral to Treatment (RTT) reporting. They didn’t have in place the appropriate governance or informatics infrastructure to deliver in line with NHS England expectations around ‘Protecting and Expanding Elective Recovery’, and our role was to design and implement an effective elective recovery programme.

Here, I set out what we achieved through a successful partnership and why it’s an effective blueprint for other trusts to follow as we approach the perennially challenging winter months.

A hands-on approach

In consultancy, there is often the temptation to go for a solution-first approach above everything else – it’s something which appeals to the problem-solving mindset which consulting attracts. How can you come up with solutions, though, before you fully understand the challenges?

To achieve this, it was important for us to be there on-site, to really get to grips with the challenges the trust was facing and then to work alongside their staff to build sustainable solutions.

Alongside some of my excellent Acumentice colleagues, we decamped for several days a week to the trust. We first spent time there on our ‘diagnostic’ to understand the systems and processes and to talk to people about what was working and what wasn’t.

This is an invaluable but too-often overlooked aspect of consultancy. The fact-finding, the scoping out, the getting buy-in from the staff who know the premises, structures, politics and processes inside out.

From this, we put together a comprehensive report, along with a number of recommendations. Chief among these was establishing strong governance for an elective care recovery programme, led by the Chief Operating Officer, with appropriate sub-committees and regular reporting. With outdated Business Intelligence (BI) infrastructure in place, it was also vital that we focused on informatics improvement. ?

A shared sense of purpose

I’ve worked in plenty of hospitals in my time and it’s certainly the case that external support can sometimes create a ‘us and them’ feel. Staff can be rightly suspicious of someone coming in from the outside telling them what they’re doing wrong and how best to improve. This can create barriers to successful engagement and implementation, as well as potentially resentment, which makes leaving a long-term sustainable legacy all the more difficult. ?

It was important to us, therefore, to show early on that we were there to work with, rather than against, the existing staff. We wanted to provide genuine hand-on support but, more importantly, create that shared sense of purpose, agreeing clear goals so that everyone was pulling in the same direction. ?

This included those working at all levels, so we supported a board development session to reintroduce execs and Non-Executive Directors (NEDs) to RTT and the principles of good waiting list management. This also provided them with assurance that the steps being taken would lead to good outcomes and they could meaningfully track progress. We reiterated fundamental principles, for example tracking by exception – to help identify the people we needed to do something about.

We also encouraged criteria-based management, using informatics and intelligence to guide people to the bottlenecks and, just as importantly, clear them.

A laser-like focus on the patient

Understandably, given the huge toll Covid took on them, staff in the NHS have been left tired and demoralised .

Fatigued by never-ending crisis management, but also with regards to national targets. On a psychological level, it’s entirely unsurprising: if you’re theoretically trying to get waiting times down to 18 weeks but struggling to get below 78 weeks, everything is going to seem a very long way off. Equally, moving from, say, 78 to 74 weeks probably won’t feel meaningful, even though it’s hard-won progress.

It’s still important to the patient, though. A month could make a big difference, especially if someone is in pain. We need to get to a stage when we’re focusing less on the end goal, more on the here and now. And celebrating any progress in getting the waiting lists down, however small, as a step in the right direction. ?

What can Trusts do differently this winter?

The recently-released Darzi report rightly leads on the importance of expanding primary care, mental health and community services instead of the traditional emphasis on acutes. He also highlights, however, that too many people are waiting for too long, and underlines the importance of improved operational management and of re-engaging and empowering staff in this challenge. ? ?

These are the lessons learned from the delivery of ‘RTT 18 weeks’ 20 years ago. Clear performance management, so staff know what’s expected of them; clear governance, so decisions get made and actions followed through; accountability, so the organisation and the system are assured of delivery; and escalation, so that problems get solved quickly by the right person. ?

They aren’t going to address systemic issues of under-investment in capital, IT and prevention, but getting ‘back to basics’ and getting the simple things right can help a tired, stressed, disheartened workforce while these longer-term changes can take place – to make the most of what we’ve got now, and start to sustainably reduce elective care waiting times for patients.