A surgical team wearing blue scrubs perform an operation in a hospital theatre.

Elective care recovery: taking a systems approach

By Neil Alexander

5 March 2024

Senior Safety Investigator, Neil Alexander, blogs about the challenges facing the NHS in tackling the elective care backlog and how learning from our investigation reports may be able to help the NHS rise to this challenge.

Neil Alexander, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB).
Neil Alexander, Senior Safety Investigator at HSSIB.

Elective care refers to when patients receive non-urgent treatment, normally in hospital, including, tests and scans, outpatient care, surgery and cancer treatment.

The NHS is currently seeing long waiting times for some elective procedures, with the Government setting an ambition to reduce elective waiting times to less than a year by 2025.

Increased waiting times mean patients have to wait longer for the care they need. This can lead to patients suffering increased pain, their condition may worsen, or they may develop other illnesses associated with the reason that they are waiting for elective care. This can cause both physical harm and mental distress to patients, their families, and carers.

We understand that many factors contribute to long waiting lists for elective care, however some of our investigations have identified some key issues that, if addressed, may have a significant impact on reducing elective care waiting lists.

Patient flow

‘Patient flow’ refers to how patients move through the care system, typically from their first contact with a hospital emergency department to when they are discharged home or into social care.

If patient flow through hospitals is not working as intended, it creates many unwanted consequences. Our investigation into ‘Harms caused by delays in transferring patients to the right place of care’ identified that ‘patient flow’ through hospitals creates safety concerns.

One of the most significant factors that the investigation explored was patient discharge to the right place of care, including social care and community care with an appropriate support package. When the healthcare system is unable to discharge patients to the right place of care, it can create serious patient safety concerns.

However, we also heard about the challenges patient flow can create for elective procedures. In our investigation we heard patient stories where elective surgery had been cancelled and patients had come to harm, due to lack of beds in the hospital.

One such case that we heard was of a patient who had their elective surgery to remove a cancerous tumour delayed because the hospital was full and no beds were available. The delay was significant and resulted in the patient’s cancer spreading, meaning the opportunity to increase their survival chances and prevent the spread of the cancer was missed. The patient was sadly put on a palliative care pathway and has since passed away.

Appointment booking systems

Our investigation into ‘Clinical investigation booking systems failures - written communications in community languages’ found there is no requirement to send out letters to patients about referrals and appointments in languages other than English.

This can mean patients need to have letters translated by another person, may miss appointments or important medical information. Missed appointments puts pressure on the system, meaning appointments have to be rebooked, potentially delaying another person from obtaining an appointment in a timely manner.

In our investigation, we focused on the family of a young child who did not receive the information they needed to make sure the child attended pre-arranged appointments, which led to a delay in the diagnosis of cancer.

Both of these investigations made safety recommendations to the healthcare system to start the process of addressing the challenges identified in them. These recommendations related to safety oversight across the health and care systems, coordinating discharge to the right place of care between health and care services, managing staff welfare, and implementing language standards to help non-English speaking patients access the right appointments at the right time.

Independent sector

Patient flow and communication are only two elements that impact elective care waiting lists, but unless the challenge of elective care waiting times is considered from a systems approach, this will continue to mean longer wait times for elective care and increased pain and distress for patients.

The significant majority of elective care procedures are still carried out by the NHS. However, it may be that the independent sector has an increased role to play in helping to tackle the NHS elective care backlog by using the extra capacity available within these hospitals (Nuffield Trust, 2023).

As our investigation into ‘Surgical care of NHS patients in independent hospitals’ highlighted, there can be challenges in ensuring NHS and independent hospitals work together to deliver safe patient care, particularly where there are unclear roles and responsibilities and limited integration of information and communication systems between NHS and independent providers.

Systems approach

As HSSIB, our remit extends to being able to investigate care in the independent sector, where an investigation could also add value to NHS care.

Elective procedures are a prime example of where a HSSIB investigation could span this boundary and help to take a systems approach to the opportunities and challenges faced in trying to reduce the NHS elective care backlog.

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