Elective recovery – the role of the independent sector

Earlier this month, the Health Foundation published a study looking at the effect that the use of private hospitals could have on the NHS backlog. Their conclusion – using private hospitals will have ‘limited impact’ on waiting lists.

At face value, the argument makes some sense, and indeed is a criticism that is frequently aimed in the general direction of the sector. Indeed we’re quite clear on this – the independent sector alone cannot solve the ongoing electives crisis in the NHS. In March 2023, around 1 in 10 elective procedures carried out for the NHS were delivered by independent providers, or a total of about 1450,000 ‘units’ of activity. Meanwhile, some 120,000 people joined the waiting list, pushing the total number waiting in England to a record 7.3 million.

What the IS does deliver, however, is genuinely additional capacity to the NHS, and capacity that can be responsive to need and scaled quickly if the demand is there. And this is where the ‘problems’ identified begin to look, well, problematic.

A large part of the study’s conclusions are based on the view that while the delivery of ophthalmology services by the IS has grown significantly over the past 18 months, this is explained by factors specific to ophthalmology and that therefore we should not expect to see similar growth elsewhere.

Well, firstly, let’s be clear – ophthalmology is a specialty where the increase in independent sector activity has been dramatic. Some months this year have seen an almost 200% increase in activity compared with 2019, before the Covid-19 pandemic. There are two key factors to this – firstly, as the study says, high volume but (relatively) low complexity activity, such as cataract surgery, is among the easiest activity to scale. Secondly, however, and arguably just as importantly, is that ophthalmology does not rely on traditional referral routes via general practice as other specialties do.

“Ophthalmology is a specialty where the increase in independent sector activity has been dramatic. As well as being among the easiest activity to scale, ophthalmology does not rely on traditional referral routes via general practice as other specialties do.”

Referral routes via optometry services tend to place fewer obstacles for patients to exercise a choice of provider – the main route for exercising choice, the electronic referral system (eRS), has seen a consistent decline from pre-pandemic levels. March saw 20% fewer first outpatient appointments made with independent providers compared with March 2019 – this despite the number of referrals made for ophthalmology patients increasing by 100%.

Here, too, approaches to commissioning come into play. The contrast to ophthalmology cited by the Health Foundation is with orthopaedics, the biggest specialty, by volume in terms of independent sector-delivered NHS activity. Orthopaedics, For the past ten months, orthopaedic activity in the sector has hovered around 107% of the 2019 baseline (a 7% increase). The study suggests that the independent sector is probably choosing not to expand more in other specialties as it makes less business sense to do so. But is this actually the case? Why do the two largest-volume specialties delivered by the independent sector diverge so significantly?

Commissioning.

IHPN members consistently tell us – and the NHS – that the single biggest reason why volumes have not increased substantially outside of ophthalmology is that the NHS has not commissioned higher volumes of work. Ophthalmology providers – with a steady, predictable and increasing flow of patients through choice-based referral routes – have been less constrained by NHS commissioning practices, and so can more confidently expand provision.

“The single biggest reason why volumes have not increased substantially outside of ophthalmology is that the NHS has not commissioned higher volumes of work.”

IHPN recently conducted a survey among our members, looking at engagement with the NHS planning process for 2023/24. In that survey, some 60% of respondents reported being asked by their local NHS to do the same or less activity as in 2022/23.

More than a year ago, independent providers made a collective offer to deliver NHS activity at a minimum of 130% of pre-pandemic levels. While that figure has been far surpassed by ophthalmology, in orthopaedics, in dermatology, in gastroenterology, in gynaecology and in general surgery – to name but the five other biggest specialties – the numbers are still far short of that offer (and in gastroenterology and gynaecology, still actually below 2019 levels). Again – these are figures driven by two key factors: commissioning choices and availability of patient choice at the point of referral.

Clearly, maximising the use of available independent sector capacity is not a silver bullet for the elective backlog. The independent sector is one part of broad range of policies needed to bring waiting lists down – just as it was in the 2000s, when it played a key role in tackling what were, then, record-high waiting lists. And the independent sector clearly can have an impact now – ophthalmology, where the sector’s contribution has seen the biggest increase, is the only key specialty where activity levels are higher and waiting times are lower than pre-pandemic.

“All of this is a rather long way of stating something rather obvious – the independent sector can only carry out activity for the NHS that it has been asked to carry out.”

The bottom line, of course, is not whether fully utilising available independent sector capacity can or will solve the elective backlog. Rather, it is that leaving potential capacity unused while the NHS is facing the biggest waiting list crisis in its history is, simply, unacceptable.

Even hitting 130% of pre-pandemic activity across every specialty could represent hundreds of thousands more people treated over the next twelve months. Clearly, for those people, making better use of the independent sector is an issue well worth pursuing.

John Hopgood
Head of Policy (Acute Care)