Covid-19 impact on waiting times for elective procedures

All of our analysis on the impact of Covid-19 on the NHS is shared here - this includes our regional tracker. For further information please contact George on 07980804956 or george@edgehealth.co.uk

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Published 23 April 2020

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This is our working paper on the impact of Covid-19 on elective procedures in the NHS. As with our previous working paper on the impact of Covid-19 on the NHS, we welcome feedback and comment and will aim to develop this paper over coming weeks.

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Outline


1. What is happening with elective procedures now?

2. What does this mean for the patients?

3. What are we expecting to see post-Covid?

1. What is happening with elective procedures now?


Following the letter from NHS England and NHS Improvement on 17th of March in preparation for influx of Covid-19 patients, trusts across England were given full local discretion to reduce elective activity as and where they see fit. Additionally, they were asked to prepare to postpone all non-urgent elective operations from mid-April for at least 3 months in the attempts to free up the maximum possible inpatient and critical care capacity[1]. While these measures will have an immediate positive effect on the incoming Covid-19 patients, they will unfortunately mean that other patients in the healthcare system will get de-prioritised.


Every month, approximately 700,000 patients are admitted for non-urgent elective operations by all medical specialties, with General Surgery, Gastroenterology and Trauma & orthopaedics accounting for approximately 35% of all admissions. With the new Covid-19 response measures coming into effect, all of these patients will have to wait for at least an extra 3 months before getting treated.

2. What does this mean for the patients?


This means, that many patients will experience long-term effects of Covid-19 measures: we are expecting to observe increased number of missed diagnoses, complications of conditions due to delayed treatment and increased level of anxiety and worry about health issues in millions of people.


People waiting for endoscopy, blood transfusions, knee replacements and many other procedures (top 20 are shown on the chart below - these account for approximately half of all procedures) will be put on hold.

All of the above will mean that coming out of the Covid-19 crisis, the NHS will be faced with yet another one, potentially less urgent but more long-term (if not indefinite), crisis.

As of January 2020, there were about 4.5 million patients waiting to start their treatment, with more than 700,000 of them waiting for longer than 18 weeks.[2]


Assuming that the numbers are about the same in mid-April, the waiting time for all of them will be extended by at least 3 months. Some[3] of these people will no longer require treatment (for example, due to developing a new condition or reconsidering their decision to undergo treatment), but the new patients will keep arriving, even if the rate of arrival will be slowed down due to postponed screening and diagnosis[4].


With new patients arriving at a constant rate and some of the waiting patients leaving the queue, the median waiting time will shift from 8.5 weeks to 13.5[5] and the waitlist size will rise by an extra 2.7 million across all specialties at the end of the 3-month cancellation period.

With NHS already struggling to hit the 18-week RTT targets and the waitlist size growing each month, the consequences of Covid-19 measures may be frightening.


3. What are we expecting to see post-Covid?


In a simplified world, where all the procedures are deemed to be equally important, patients get treated in the same order as they are added to the waitlist (i.e. no prioritisation of urgent patients takes place in this scenario which is clearly unrealistic) and the NHS does not increase its capacity, everyone would have to wait on average 5 weeks longer4 and the waitlist size will go up by 2.7 million, hitting a record of 6.8 million. To clear this number of backlog patients, NHS would have to run at 125% capacity for the whole year (or 112.5% for 2 years).

This means, that if in pre-Covid times an average patient would have waited 9 weeks for a hip replacement, after April they would wait on average 14 weeks - a 55% increase in waiting time. However, this is unlikely to happen due to two main reasons:

  • Not all operations are equally urgent: while painful, a delay in hip replacement is unlikely to threaten patient’s life in the same way a delay in cancer treatment would and

  • NHS is unlikely to return to its usual capacity immediately after the elective procedures restart: most likely, some Covid-19 patients will still be in beds and will need to be take care of.

If we consider a prioritisation scenario where 20% of the patients on the list become urgent[6], the first two months after the restart of elective procedures will be spent on treating only urgent cases, while the less urgent ones would be pushed further down the list[7]. Quite worryingly, this would mean that a patient who starts waiting for a treatment now might have to wait for at least half a year[8] before they are even considered for an elective procedure. If we account for the fact that some of the hospitals’ capacity will still be needed to treat Covid-19 patients, the time spent on treating urgent cases shifts from 2 to 5 months.


The waitlist meanwhile will keep growing, as the new patients keep arriving. Some of them will be urgent – hence pushing the non-urgent waiting patients even further. From the chart above it is evident that the rate at which patients were being added to the waitlist exceeded the rate at which they were treated even before the coronavirus hit the NHS. After this is over, the situation will only get worse.


A potential (and probably the sole) solution to this crisis would be to increase the rate at which patients are being treated. As mentioned above, to clear the backlog, NHS would have to run at 125% capacity for the whole year. A tough task for the NHS which will have no time to recover from the damage the coronavirus has caused before an action would be needed.


To achieve this increased rate of treatment, three main paths can be considered by the NHS:

  1. Improving theatre efficiency. An average of 300 operations10 will need to be added to each theatre in the next year to work through the backlog of elective procedures.

  2. Purchasing extra services from the private sector. If the NHS keeps its current level of operation, the services worth of 750 NHS theatres operating at full capacity would have to be purchased.

  3. A mixture of options 1 and 2. While an increase of 25% in theatre efficiency seems unrealistic, some of it is achievable. The rest of the backlog might go through private sector.

Option 3 might be optimal: it is both not beyond the realms of possibility, like Option 1, and not as costly as Option 2. The next question to answer then is where do we draw the line: how much of the capacity will be gained through improved efficiency, and how much of it will be bought.


According to the report from Getting It Right First Time (GIRFT), trusts can increase their throughput by a substantial amount if their scheduling is improved (through reducing the number of late starts, early finishes and delays in between operations)[9]. If this is to be the case on the national level, and the NHS manages to up their operations by 13%, only 12% of activity will have to go through the private sector (360-theatre’s worth of activity). Alternatively, at this level of operation, the NHS will be able to clear the backlog in 2 years without external help, a tough ask in these trying times.


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[1] https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/20200317-NHS-COVID-letter-FINAL.pdf [2] 700k seems to be a common figure in the NHS these days! No relation to the number of elective procedures above. [3] Here we assume 92% of patients on the waitlist will still require treatment after the cancellation measures are lifted: based on the proportion of patients not treated 28 days after cancellation of their procedures https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2018/11/NHS-cancelled-elective-operations-commentary-Q2-2018-19.pdf [4] We assume 80% of pre-Covid rate of arrival. [5] Shifting all the existing patients by 12 weeks, then adding 12 weeks’ worth of new patients (arrival rate is constant as shown on the chart hence the number of waiting patients is the same for 1st, 2nd, …, 12th weeks), then calculate new medians using the new data. [6] This figure will vary widely based on specialty and type of organisation 20% is used for illustration here. [7] Based on the assumption that activity will be restored to pre-Covid level of 700,000 procedures per month. [8] 13.5 weeks from earlier on + 2 months for urgent patients hence 13.5+8=21.5 ~ 5.4 months [9] https://improvement.nhs.uk/documents/3711/Theatre_productivity_report__Final.pdf




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