The need for a unified approach to managing elective patients during the pandemic

In dealing with this latest and most challenging phase of the pandemic, one point of potential solace is that the service now has the benefit of knowledge developed during previous waves.

This hard-won experience can not only be valuably harnessed in treating patients with coronavirus. It can also help inform effective management of those whose planned care is affected by the demands of the pandemic.

When the first wave of covid hit, and with it the need to cancel nearly all elective activity to meet the demands of a novel virus, there was little guidance on how to make such decisions.

But as the service confronts this latest and unparalleled surge, and again faces choices over which planned elective admissions will need to be delayed, there is formal national guidance in place alongside the benefit of previous experience.

Prioritisation

In September, NHS England and NHS Improvement issued details of its clinical prioritisation framework, centred on the idea that there should be “clinical validation” of surgical waiting lists – checking the patient’s condition and risk factors, considering the possible level of harm should an admission be delayed, and communicating with patients and GPs to make the best decisions about how to proceed.

With this framework came the request to complete a clinical review of all patients on an admitted pathway and to begin regular reporting on these numbers from the middle of December.

Yet the reality is that different organisations will have had differing abilities to complete this task. This is down to varying resource: both staff required to undertake the work, and availability of the best systems and data for the work to be completed quickly.

In addition, while the process of prioritisation has been described, the way in which it should be performed has not. Translating a national directive into the operational context – taking an output and deciding on the appropriate inputs to achieve it – is not always straightforward.

It leaves open the possibility for organisations, even within the same local health and care economy, to take subtly different approaches to validation and prioritisation of waiting lists.

Elective care leads must be in a position to respond quickly and effectively when plans need to be changed, which may require support from senior managers

In every instance, robust decisions on individual cases will have been made by appropriate clinical teams. However, those involved, how the process is managed and reported, and how those decisions have been validated varies between organisations.

What the first wave has shown is that this sort of variation in approaches is a sub-optimal way of tackling this challenge. That’s not least because it is not solely at organisation level that NHS England and NHS Improvement’s attention is focused. Accountability is now firmly shared between trusts and at the STP/ICS level.

Indeed, the covering letter issued with September’s clinical prioritisation guidance stated that “managing elective waiting lists at system level will play a critical role in recovering elective activity”.

Yet if different organisations are taking different approaches to this process – or indeed have varying availability and/or quality of data – then any system-based reporting risks becoming disparate. Certainly developing, maintaining and assuring these processes will not be without the need for resource and effort, and is unlikely to be streamlined or frictionless.

At Acumentice, the providers we have seen complete the work of elective deferral, prioritisation and recovery preparation most effectively are those operating in a joined-up way as part of a wider local system. That means all organisations in an area taking the same approaches, but it typically also means use of digital tools to gather and share this complex information across a footprint.

Where trust leaders are unsure about whether their approach is consistent with that of neighbouring organisations, or indeed unsure which digital tools are being used and what opportunities they do (and do not) present, there are valuable conversations to be had to clarify and refine approaches.

Provider organisations will need to continue careful monitoring of activity and use of capacity during this surge period. Elective care leads must be in a position to respond quickly and effectively when plans need to be changed, which may require support from senior managers.

There is also an opportunity now to create a patient tracking list that covers multiple providers rather than single organisations. This would support in the next phase of elective recovery and in directing resources to appropriate priority groups.

Yet while this concept has been proposed in national guidance, there is not yet a standardised definition of it – or a shared understanding of what digital systems support it. At Acumentice, we are dedicating to helping clients understand the different possible approaches and the possible benefits of shared lists.

The NHS now knows many of the most important ingredients for success in reprioritisation and ongoing management of elective care patients during this pandemic. Ensuring that those approaches are present throughout local systems and, indeed, throughout the country will not only benefit the service at this enormously pressurised time. It will, crucially, help ensure elective patients are being cared for as effectively as possible during a period of great constraint.