The NHS’ Balancing Act: Prioritising Urgent Cases While Tackling the Elective Backlog

Over a year ago (February 2022) NHSE set out clear targets for maximum wait times for elective care, as part of the plan for dealing with the pandemic-induced backlog.
The aim has been to achieve zero 78-week waits (78WW) by the end of last month, zero 65WW by March 2024, and zero 52WW by March 2025.

Let’s explore this operational challenge

A look at the data will show that around 5% of the RTT waiting list is waiting over 52 weeks, and only 0.8% over 78 weeks.

This seems like a fraction of the total waiting list – why can’t we just treat all of those patients straight away?

The amount of long waits varies across the country

There is significant variation in the waiting lists between systems. In some ICSs, 0 patients are waiting over 78 weeks already. In others, almost 3.5% of patients have been waiting over a year and a half.
Crucially, the challenges vary between specialties. An example of this is the ENT operation for septorhinoplasty, or “nose job”, a procedure whose high complexity and relatively low clinical urgency means that patients waiting for this surgery often must wait over 1.5 years.

The question remains – why can’t existing capacity be diverted to those long waiters, to clear the backlog in 1-2 months?

Systems are actively targeting long waits – though there is no “quick fix”

When we compare activity in December with the size of the 78WW cohort across ICSs, it emerges that many systems could clear their 78WW backlog using a fraction of monthly capacity.
In fact, on average across all Trusts, 3.3% of one month’s capacity (December 2022) could have been used to clear all 78-week waiters.

However, for other ICSs, around one in every four patients treated would have to be from the long-waiters cohort to reduce 78WW to zero.

Here are two reasons this would not work.

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The Patient Tracking List (PTL) for elective surgery is a “live” document

Much like a Google doc, the PTL is constantly changing.

One hospital could have 100 patients waiting over 78 weeks on February 1st. Even if all of those particular patients were treated this month, several more will cross the 78+ week threshold as the month progresses.
This means that the activity required to reduce 78WW to zero is actually much higher than just number of 78WW that we have right now. It includes patients who are also about to approach the 78WW mark.

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We cannot forget about risk

Typically, Trusts will apportion capacity based on risk – the most clinically urgent cases (emergency admissions, cancer patients) need to be seen fastest and will be bumped to the top of the queue.

A score often used to allocate priority – the “P” priority score, developed by the Royal College of Surgeons -, is a time-based measure of risk that focuses on mortality. Patients within the 78WW cohort were assigned low mortality risk scores on triaging, which has contributed to their growing wait as more clinically urgent patients have been seen first. While there is evidence that waiting for care for prolonged periods can carry substantial morbidity, the issue of mortality risk remains.

Juggling finite resources remains a conundrum

Prioritising 78WW patients may take away capacity from the most urgent patients. On the other hand, not addressing the backlog causes longer and longer waiting lists, and increases risk that some of those patients will need urgent care. Operational and clinical teams handle this balancing act on a daily basis – it is essential that they have access to timely, accurate and insightful data that support their decisions, ensuring that they can safely and effectively managing waiting lists.

In the next blog, we will explore innovative methods that operational teams are using to tackle the elective backlog, and highlight the tremendous work by specialty teams to overcome their unique, specialty-specific challenges