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How insourcing can reduce waiting lists

By Claire Dubowski
4 December 2023

Recent analysis from the Health Foundation has shown that NHS waiting lists are anticipated to rise to an all-time high of 8 million, and not fall until next summer. While understandably these waiting lists have been a significant political priority for the Prime Minister Rishi Sunak, as well as Labour leader Sir Keir Starmer due to their significant effect on voters and the general public, these waiting lists are also having a harmful impact on those working in hospital systems.

The Health Foundation report states: ‘Crucially, we must also improve staff morale and retention. The government’s commitment to grow the healthcare workforce is welcome. However, recruiting new staff is only half of the solution. Providing a supportive, well-resourced working environment is vital to reducing burnout.’

Despite these robust calls for improvements, dissatisfaction among NHS staff is well known, as demonstrated by ongoing strikes in recent years, as well as the 2022 NHS staff survey, which showed that a third of NHS employees were considering leaving their jobs. These lengthening waiting lists also have a snowball effect – the longer patients wait, the sicker they get, and the more complex their needs become. This means that NHS staff then have limited ability to deal with the backlog itself because more complex health problems are being created for patients who are delayed in getting what should be routine treatment.

As integrated care systems (ICSs) are financially incentivised to exceed elective surgical capacity, while also being at risk of underperforming against pre-Covid targets due to limited resources, this further strains NHS staff, damaging staff morale. The scale of the waiting lists is so significant that it undermines the necessary process of targeting those patients who need to be seen in order to avoid the problem of them becoming significantly more ill in the process. While there are some systems in development to help support this issue, including AI technology, these are not yet of the scale required for such colossal waiting lists.

One solution to this issue is for NHS trusts to commission insourcing to fill gaps in capacity. Insourcing is a practice where a team of highly qualified doctors are brought in to use theatres and equipment in the evenings and weekends when they are not currently being used. By effectively using equipment and theatre space that would otherwise lie idle, many more patients are able to be seen on the weekend and in the evenings, helping NHS trusts to provide a ‘7-day service’ to patients, including working people and those with caring commitments who can struggle to juggle weekday responsibilities with NHS appointments.

This solution has proved popular with the general public, with recent YouGov polling showing that 71% of Brits support insourcing as a means to cut waiting lists, if treatments remain free at the point of use. This has benefits for both patients and trusts – insourcing offers a more cost-effective option in contrast to outsourcing, as they charge lower than market rates per treatment whilst also integrating their service into already functioning NHS hospitals. The government recently acknowledged the enormous potential that the independent sector can play in combating the elective recovery backlog as part of their Elective Recovery Taskforce plan, which shows that there is a political will to deal with this public health challenge.

Unlike agency workers, insourcing companies can offer full teams to come and perform procedures at the hospital instead of ad-hoc gap-filling, as often happens with agency staff. The best way to utilise capacity is not by being a last-minute solution but by being a long-term partner in improving productivity. It also allows patients to be treated locally, in contrast to the recent plans proposed to offer patients a chance to travel across the country to be treated to cut down waiting lists. While such plans are understandable, the principle of ‘patient choice’ is rather undermined when a patient has been languishing on a waiting list for over 40 weeks and then might have to travel far away for treatment.

The need for insourcing is laid bare by polling by the Medical Protection Society (MPS), which found that 47% of doctors were concerned about the impact of burnout on patient safety. Nearly half of these said that referral waiting list times, along with the concern about patients having to wait, were having an impact on their mental health. Others cited exhaustion (55%) and the inability to take breaks to eat and drink (50%) as factors having an adverse effect on their mental health. This demonstrates that long waiting lists affect not only hospital staff directly, but also other health professionals across ICSs.

With the capacity advantages of insourcing, trusts will be far more able to efficiently provide a ‘well-resourced environment’ for staff to work in, at a lower tariff than outsourcing and seamlessly integrated within an ICS and its providers. The positive effects of this can be found across systems, as insourcing companies are able to provide additional surgical and diagnostic activity across ICSs. Insourcing companies can also provide a range of additional services, including key support on clinical triage and booking and scheduling patients. This additional shouldering of administrative burdens would have the potential to help identify at-risk patients who are not being adequately prioritised due to the current scale of waiting lists.

A recent example where 18 Week Support has made a substantial difference was when a large NHS Foundation Trust was having serious capacity issues in its endoscopy service – they could only see 55 patients per month. As a result, the six-week waiting list had grown to 689 patients. Collaborating with the Trust, our operational teams and clinical lead designed a bespoke service to bolster capacity at the Trust and provide our clinical teams on weekends, with the ability to flex to meet variations in demand and need.

On each list, we maximised clinical excellence and the number of patients who could be safely treated. In just four months, the total endoscopy activity carried out at the trust increased substantially, and the six-week waiting list was reduced by 87%. As a result, the Trust has seen a total transformation of its waiting lists and activity levels.

All of us who care about the NHS, especially those who work within the service, want patients to receive the best treatments available, quickly, and in an environment they know. Insourcing is already helping to solve this problem at NHS trusts across the country, and I hope this good work can continue as we look to the future.

Claire Dubowski is the Chief Executive Officer of the NHS insourcing company, 18 Week Support. 18 Week Support has worked with over 100 trusts across the UK, performing over 250,000 procedures annually. More information on 18 Week Support is available here.

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