Waiting on the NHS

The latest data from NHS England shows that in spite of all attempts to reduce waiting lists remain stubbornly static at 7.6 million patients waiting to start treatment. The number waiting over two years rose by 55 to 282, while 13,164 patients have been waiting over eighteen months, though NHS England’s targets were to have nobody waiting that long.

Waits longer than 65 weeks are supposed to end by 31 March, but those numbers have increased too, up 3,811 to 98,374. Only 58.2 per cent of patients are treated within 18 weeks. The 18-week treatment target has not been met since 2016.

In urgent care, patients routinely wait on trolleys in corridors and ambulances stand outside hospitals, unable to unload patients and go to their next call. This is no longer just a winter problem but familiar all year round.

Four-hour waits are unremarkable – the maximum four-hour standard set in the NHS Constitution has not been met since June 2013. Indeed, twelve hour waits, a rarity ten years ago with 489 in the whole year, now average 1,440 a day.

Lethal

These waits for urgent care can be lethal. A study in the Emergency Medicine Journal published in 2022 found that “for every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death”. The Royal College of Emergency Medicine has called on the government to tackle the root causes of “exit block” and to act now to increase staffed bed capacity.

There is also a shortage of emergency medicine staff. The RCEM, along with the Royal College of General Practitioners, Royal College of Physicians, Royal College of Psychiatrists and the Society for Acute Medicine, published recommendations at the end of the pandemic for improving services, but many of these have not been acted on.

In primary care, a 2023 report from Healthwatch, which coordinates feedback from patients, reported a lack of access for patients. Appointments are often unavailable, telephone or online contact difficult

or impossible, service hours limited, and there is over-reliance on virtual contact with a GP or nurse. Transport difficulties can prevent access to services some distance away, and the high costs of long waits on the telephone and repeated calls can be prohibitive.

Research by the Nuffield Trust similarly found that, while more GP appointments are being offered in absolute terms than pre-COVID, in 2023 a lower proportion are offered within a week.

Central

Central to recovery in the NHS are the highly skilled clinical staff, doctors, nurses, and other professionals. Pay has fallen dramatically, leading to unprecedented strike action.

On 9 February, junior doctors announced more strike days at the end of that month, and opened a new ballot on industrial action, closing on 20 March, while consultants in England have voted by a small majority, 51 per cent, to reject an offer, and have reopened talks. While the junior doctors have until now won large majorities for strike action, they should reassess the sense of pursuing these tactics inflexibly.

‘The maximum four-hour standard set in the NHS constitution has not been met for years…’

On strike days locums, and numbers of International Medical Graduates (doctors imported from abroad) work normally, and on most days their consultant colleagues have provided cover. The current approach risks dissipating the unity the junior doctors have shown hitherto, and the support they have enjoyed from other workers and patients.

There are issues beyond pay. Doctors need to tackle the increasing use of Physician Associate posts. Originally called Physician Assistants, they were intended to free doctors in training posts, and others, from routine administration, so they could concentrate on clinical duties, and training.

Physician associates have two years of training, in contrast to the five year (minimum) medical degree required for doctors. Over 4,000 work in hospitals and general practice, and the General Medical Council estimates 900 new ones qualify each year.

In practice, employers have used associates to dilute the skills of the medical team. Some of these associates have misrepresented themselves to patients, with employers’ connivance, as qualified doctors.

Risk

In one case, an associate working in general practice twice misdiagnosed a patient with a blood clot, first as having a sprain, second as having long Covid and anxiety. The patient collapsed and died in hospital. In a BMA survey, 87 per cent of the doctors who took part said that the way physician associates and anaesthetic assistants currently work was always or sometimes a risk to patient safety.

Physician associates are not currently regulated, though there are proposals before parliament to bring them under the aegis of the General Medical Council.

The BMA is calling for the Health and Professions Council to regulate these posts. It wants the assistant part of the job title reintroduced, and a moratorium on their recruitment until their role and scope of practice is clearly defined.

Under the NHS Long Term Workforce Plan, to be welcomed since workforce planning has up to now been done in secrecy, there are proposals to reduce medical training to a four-year programme, via internships. This baffles medical educators, who struggle to fit the rapidly developing world of medical knowledge into the current curriculum as it is.

The plan further relies on the supposed benefits of applying artificial intelligence, AI, for which there is yet little real-world evidence. As the BMA points out, an overemphasis on technological solutions will not work – staff need training, skills and time to use new technologies effectively.

For every profession in the NHS, fighting for pay and to protect skill are inseparable; hard thinking is required to determine collective responses. The working class more generally must make its voice heard too.

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