NHS targets require flexibility during the coronavirus crisis

At the start of the Covid-19 pandemic, NHS England told NHS Trusts to postpone all non-urgent medical operations between 15^th and 29^th April. Ensuring that hospitals weren’t overwhelmed was the right thing to do but delaying medical care has had serious consequences.

There were almost 13,000 excess deaths in England and Wales – deaths above the average over the last five years – not attributable to coronavirus between 21^st March and 25^th April. The Office for National Statistics found that some of these excess deaths could be explained by delayed access to medical care, particularly for diabetes, epilepsy, and hypertensive diseases. The longer that patients wait for care, the bigger the risk that their illness will be fatal – particularly for diseases where early diagnosis increases the likelihood of survival, such as cancer, heart disease, and stroke. As a result of fewer hospital appointments taking place during March and April, just over 110,000 people were waiting longer than a year for an operation in August, compared to just over 3,000 in March.

As coronavirus cases in hospital fell NHS England and Improvement, the non-departmental public body which manages the NHS in England, responded by introducing a series of targets designed to increase services. As coronavirus cases are now increasing, NHS England and Improvement need to revise their plans.

Reintroducing targets was the right decision and contributed to trusts rapidly restoring services over the summer

After the first wave, NHS England and Improvement set NHS Trusts goals for hospital activity on 31^st July in their ‘Phase 3 guidance’. These goals were converted into targets – with financial penalties if they were not met – on 20^th August. The targets were designed to encourage NHS Trusts to provide as much non-coronavirus healthcare for patients as possible between the summer and winter. From September, NHS England and Improvement told Trusts that part of their funding was contingent on performing a certain number of appointments, diagnostics, and operations each month.

When NHS England and Improvement set the targets, the number of people with coronavirus in English hospitals was low. There were just 807 patients with coronavirus in hospital on 31^st July, compared to 18,970 at the peak of hospitalisations on 12^th April. Setting a target at the end of July was justifiable and may have helped focus NHS staff to provide non-coronavirus services while maintaining enhanced infection control such as deep cleaning hospital equipment.

Owing to greater use of technology and redesigned services – such as repurposed waiting rooms, relocating some services from acute site to community hubs, and more remote appointments – NHS Trusts have rapidly increased activity since April, in many cases getting close to the same levels they reached in 2019.

 

Keeping the targets in place during a second wave would be counterproductive

While the targets may have helped at the start, however, they are no longer appropriate.

Coronavirus hospitalisations have been steadily increasing since 1^st September, and as of 11^th October there are now 3,451 patients with coronavirus in hospital – higher than when the government first imposed a national lockdown on 23^rd March. With rising numbers, Trusts will have to reorganise and redeploy staff to respond to the crisis. Hospitals in Liverpool have already started reducing elective activity and preparing to redeploy staff, for example.

With rising cases, imposing fines for not meeting activity targets would be counterproductive. The biggest determinant of Trusts’ ability to undertake routine operations is the number of coronavirus patients they have to treat – fines will not affect their ability to treat patients. Keeping national targets in place risks dangerous behaviour if Trusts feel pressured to provide non-covid care when it is unsafe to do so.

If NHS England and Improvement keep the targets in place, then they should vary the targets by region, acknowledging that the number of patients in hospital with coronavirus vary significantly across the country.

5% of general and acute hospital beds in the North West are occupied by patients with coronavirus, compared to 2% in London, and just 0.4% in the South West – blanket national targets are inappropriate in this context.

Throughout the crisis NHS England and Improvement have sensibly flexed the targets regime to allow hospitals to focus on patient needs. With the second wave upon us, they need to flex it again, and quickly.