Guidance

Elective recovery taskforce: implementation plan

Published 4 August 2023

Applies to England

Foreword

The COVID-19 pandemic posed a once-in-a-lifetime challenge to the health and livelihoods of each and every one of us, and the entire health and care system that supports us. A challenge that the NHS and independent sector healthcare providers faced together head on.

Appointments were rearranged across the NHS as dedicated COVID wards were rapidly deployed, tens of millions were vaccinated at a pace never seen before, and schedules were cleared across countless independent sector providers to continue providing care to people in need, free at the point of use.

A shared test, met with a shared response.

As the country emerged from the peak of the outbreak, the ongoing impact on patients and public services was apparent, including the backlog for elective care and the millions who continue to wait as a result.

Another shared test, that demanded another shared response.

A shared test that has seen the NHS draw again on the long history of the independent sector, delivering high-quality care for NHS patients, free at the point of use.

The delivery plan for tackling the COVID-19 backlog of elective care set out the detail of this system-wide response – with patient choice at its core.

It committed to offering more appointments, more diagnostics, and a genuine choice about where people were treated – be that at their local NHS provider or independent sector provider, free at the point of use.

The Elective Recovery Taskforce was established to maximise all the capacity available to us – be it within the NHS or the independent sector – and this report sets out the practical steps we are taking to make this a reality.

These concrete actions are the result of the entire health system working together as one. The delivery of these actions will speed up the treatment of patients by championing their right to choose where and when they are treated. Our expectation is that these measures will quickly play a key role in increasing the use of independent sector capacity across a broader range of specialties, helping to get NHS waiting times down and ensuring every patient can realise their right to choose where they receive their NHS care.

Will Quince MP (Chair), Minister of State, DHSC
David Hare, Chief Executive, Independent Healthcare Provider Network
Sir Jim Mackey, National Director of Elective Recovery, NHS England

Executive summary

Since February 2020, the elective waiting list has grown by 61% from 4.57 million to 7.47 million. The delivery plan for tackling the COVID-19 backlog of elective care set out the system-wide response to reducing this backlog.

The independent sector demonstrated its ability and willingness to work collaboratively with the NHS towards a common goal during the pandemic. It currently delivers 6% of diagnostic tests, and 9% of appointments or treatments that completed a patient pathway and removed them from the waiting list,^{[footnote 1]} with even more care delivered through close partnerships with NHS providers.

All independent sector activity undertaken on behalf of the NHS is delivered free at the point of use (and independent sector providers (ISPs) are paid in line with NHS unit prices), upholding the founding principles of the NHS that access should be based on clinical need, not an individual’s ability to pay. ­­­­­­­­­­­­­­

Maximising the use of all NHS assets and available independent sector capacity is a key part of the plan to tackle the elective backlog and, while use of the independent sector is up, this is concentrated in specific specialties.

The Elective Recovery Taskforce was set up in December 2022 to advise and inform the Secretary of State for Health and Social Care and the Prime Minister on how to increase the volume of elective consultations and procedures by both the NHS and the independent sector as far as possible to tackle the backlog.

The taskforce, chaired by Minister Will Quince, brought together leading voices from across the NHS, independent healthcare sector and patient representatives to collaboratively come up with solutions.

The taskforce concluded at the end of March 2023, agreeing to work together to implement action in 4 core areas:

• empower patients to exercise their right to choice
• deliver a post-pandemic recovery
• enable longer-term system sustainability
• deliver this plan and go further

The actions are set out in this implementation plan, with a summary at Annex A. Following the conclusion of the taskforce at the end of March 2023, the focus has turned to delivery and putting these actions into practice, with appointees invited to convene after 6 months to review progress.

Implementation plan

Empowering patients to exercise their right to choice

Patients have a right to choose their provider of consultant-led services at the point of referral. This can drive faster treatment times and better outcomes.

The taskforce identified barriers to empowering patients to exercise their right to choose where they are treated, including:

• clinician and patient knowledge of their rights
• an issue with the electronic referral system (e-RS) where there were 2 menus to choose services from, which added complexity to referrers viewing all available providers
• a lack of reporting data on whether patient choice has been offered consistently
• technological barriers to patients being able to manage their care pathway

In February 2023, NHS England expanded the My Planned Care service to enable patients to compare waiting times across all providers within a specialty.

The NHS’s My Planned Care platform enables patients to compare different providers in their local areas, and the expected waiting times at each.

Earlier this year, independent sector providers were added to the platform, enabling patients to compare average waiting times between NHS and independent sector providers.

NHS England will continue developing waiting time information over 2023 to improve accuracy, and ensure referring primary care professionals and patients have access to the same information.

In May of this year, the government and NHS England also set out how they will make it easier for patients to exercise their choice (covering NHS services provided free at the point of access by both NHS and independent sector providers) by improving the NHS App, increasing choice for patients already on waiting lists and raising awareness of patients’ right to choose.

Actions

To support this ambition, the taskforce and the organisations represented on it are taking action including the following points.

Following improvements to the e-RS, referrers can now see all potential healthcare providers in a single menu that can be sorted by waiting times, informing conversations with patients of the options available to them. NHS England has rolled out communications to GPs on the changes to e-RS to ensure choice is consistently offered at referral.

Patients will be actively offered a shortlist of a minimum of 5 providers, where clinically appropriate, and patients are able to see provider quality, waiting time and distance to travel in My Planned Care.

The NHS is making further changes to make it easier for patients to manage their appointments by rolling out patient engagement portals across England. Once the portals are established and linked up with the NHS App, patients will be able to view their appointments and request to change their appointment. By September 2024, we expect up to 90% of trusts to have done so.

The Digital Mutual Aid System (DMAS) is an existing national system that facilitates mutual aid requests and offers between providers, including independent sector providers (over 99% of independent sector providers are signed up). NHS England is developing a patient-initiated DMAS that will enable patients to request to move provider. From the end of October 2023, all patients who have waited more than 40 weeks without having had their first outpatient appointment will be able to initiate a request to transfer to another provider. We have set an ambition to expand this solution to further long-wait cohorts in future, depending on the level of uptake and impact on clinical capacity.

DHSC and NHS England will run a patient-facing comms campaign starting from August 2023 to ensure patients know about their right to choose and how to exercise it, and clinicians are prompted to offer choice at the point of referral (including to the independent sector) through e-RS.

DHSC, with NHS England support, will update the NHS Choice Framework to help patients understand the choices available to them in the NHS. The updated framework is likely to be published in August 2023.

NHS England are working to establish a baseline position for how many patients are currently accessing choice. This baseline will be made up of a measure of percentage of patients who were offered choice at the point of referral, and the average number of providers a patient is offered on a shortlist.

Delivering a post-pandemic recovery

While there have been increases in the use of the independent sector, some specialties (for example ophthalmology) have seen bigger increases than others. The taskforce identified a range of barriers to maximising the role of the independent sector in reducing the backlog caused by the pandemic. These prevent systems from realising the potential capacity available to them and, in turn, lead to patients waiting longer as a result. The identified barriers include, but are not limited to:

• obstacles to new providers offering healthcare services
• payment mechanisms that provided some stability to the health system during the COVID-19 pandemic, but would not sufficiently incentivise providers to increase their activity level as we moved into the post-pandemic recovery
• challenges in spreading good practice between systems and providers

NHS England set out a clear priority to include ISPs in local plans to tackle the backlog within its 2023 to 2024 priorities and operational planning guidance to establish a clear expectation and foundation upon which to build. The Independent Healthcare Providers Network also runs an annual survey, which is used to monitor the extent to which ISPs are actively engaged in local planning activity.

The NHS guidance also set out a return to paying according to the amount of elective activity delivered to allow integrated care boards (ICBs) to move elective activity across providers, including to independent sector providers.

The taskforce supported 2 projects on long waits, which took place in Birmingham and Solihull ICB, and Leicester, Leicestershire and Rutland ICB. The projects implemented different approaches to boosting diagnostic and treatment capacity. Lessons learned from these projects are set out below and have been taken forward as part of NHS England’s independent sector programme, which is aimed at delivering increased levels of NHS activity.

Case study: reducing long waits project

At the first meeting of the taskforce in December 2022, the taskforce agreed to conduct a targeted piece of work considering how the independent sector can support with tackling the long waits targets set out in the elective recovery delivery plan.

Birmingham and Solihull (BSol) and Leicester, Leicestershire and Rutland (LLR) were identified as coverage of the independent sector in these 2 systems have varied significantly, with both systems having some of the largest cohorts of 78-week waiters in the country.

The project looked at methods to maximise the use of the independent sector in tackling the backlog by comparing different approaches across different ICBs, highlighting and capturing the established work already being conducted. This included the use of both outsourcing and insourcing.

Outcomes

Both areas considerably changed their use of the independent sector over the course of the taskforce.

LLR expanded its independent sector infrastructure by doubling the number of independent sector providers they contracted or were in discussions with for future service provision.

Supported by the system, BSol strengthened relationships and utilised available independent sector capacity, resulting in a significant increase in patient volumes being transferred to the independent sector providers.

LLR saw an increase of 71% in independent sector activity in 2022 to 2023 compared with 2019 to 2020 levels, with a plan for 2023 to 2024 activity levels to reach similar levels.

BSol has forecasted it will have no patients waiting over 78 weeks by end of July 2023 and will have seen around 35,000 long-waiting referral to treatment (RTT) pathways completed by 9 separate ISPs since December 2021.

Key lessons

ICBs and ISPs should conduct more timely joint strategic planning of all available capacity over multiple years, in line with NHS England’s existing operational planning guidance.

Coordination with ISPs should occur at ICB level, rather than the independent sector working solely through NHS trusts.

ISPs and NHS providers should agree appropriate patient prioritisation to ensure that the longest waiters are given suitable priority for available care.

ISPs and ICBs should work to strengthen alignment of patient level data at and between both system level and independent sector level. This will allow for more careful monitoring and sharing of patient level information, enabling oversight of the whole patient pathway.

Transferring of whole pathways to the independent sector could provide more efficiency for the trusts and reduced duplication for the patient.

Actions

The taskforce and the organisations represented on it are taking further action, including:

• NHS England published new guidance in July 2023 that clarifies NHS England’s role in overseeing and ensuring commissioners operate in compliance with their obligations in line with current legislation

• subject to the Parliamentary timetable, DHSC aim to revise patient choice legislation and establish the Provider Selection Regime (PSR) in 2023

• revised patient choice legislation will ensure that provider qualification criteria are used more consistently and make clear the circumstances under which NHS England and ICBs must offer a contract to providers that meet the qualification criteria. DHSC and NHS England will work with the system to ensure that it is prepared for legislative change and that it is implemented successfully

• NHS England will update NHS Choice guidance in line with revised regulations on patient choice in 2023. This guidance will help ICBs make NHS Choice work well for the populations they serve and will be published on the NHS England Choice guidance page

• the PSR will be a new regulatory regime to govern the procurement of healthcare services in England. This is intended to improve avenues for providers who are suitably qualified to deliver clinical services

• to further assure decisions around patient choice and procurement under the PSR, DHSC and NHS England intend to introduce an independent panel which will review compliance with patient choice and PSR requirements. This panel will, when required, provide advice to commissioners to assist with improving compliance where necessary

Enabling longer-term system sustainability

The taskforce considered the importance of ensuring the NHS and independent sector has access to a sustainable workforce and facilities to provide additional capacity – both now and in the future.

The taskforce agreed that healthcare workforce size and productivity are key challenges to recovering elective performance. The NHS long-term workforce plan, published in June 2023, sets out a plan for the NHS to recruit and retain more staff.

Since the pandemic, thousands of junior doctors have received training opportunities in the independent sector. Many ISPs also offer apprenticeship opportunities, including some offering nurse apprenticeship programmes. ISPs have also offered training opportunities to other professionals including radiographers and physiotherapists.

Against this backdrop, the taskforce recognises that there is more to do to ensure as many training opportunities as possible are provided in the independent sector where these can boost the overall healthcare workforce.

The taskforce explored the benefits of enabling junior doctors to gain access to practice opportunities in ISPs, particularly where ISPs undertake a high volume of overall procedures, to boost the range of opportunities to develop these skills. Facilitating this is dependent on:

• easing the administrative burden on doctors moving across providers, often involving lengthy employment checks, which can act as a deterrent against moving
• forming strong local relationships between NHS organisations and the independent sector to enable providers to provide junior doctors with training experience through first-hand experience of procedures

The taskforce considered what would be required to attract investment from the independent sector in new diagnostic capacity in particular. This would support the longer-term delivery of the elective recovery plan, and aligns with the ambition for additional independent sector diagnostic provision highlighted in the Professor Sir Mike Richards Review to boost overall capacity.

To facilitate this, the taskforce identified a set of barriers and enablers to medium and long-term independent sector investment and engagement with NHS-funded elective activity. This work highlighted the value of continuing to adopt and evaluate joint working between the independent sector and the NHS. A similar approach has been applied successfully in delivering Community Diagnostic Centres.

Case study: Community Diagnostic Centres

Community Diagnostic Centres (CDCs) form a major pillar of the elective recovery plan. To reduce the elective and cancer backlogs, significant investment has been made in diagnostics, using a model designed for the needs of the systems.

Investment in CDCs were a specific recommendation of the Professor Sir Mike Richards Review.

£2.3 billion was awarded during the 2021 Spending Review to transform diagnostic services. This will help increase the number of CDCs up to 160 which, together with investments in additional acute trust diagnostic services, will increase NHS diagnostic capacity by up to 9 million tests each year from March 2025.

Independent sector partnerships are key to delivering CDCs, making a significant contribution to delivering NHS diagnostic services. Currently, over 200 ISPs provide over 10,000 diagnostic procedures per week to the NHS.

To date, NHS England have approved over 50 schemes with independent sector involvement, including fully independent sector-led CDCs, joint service delivery models and CDCs that have made use of independent sector-delivered mobile diagnostic facilities. As part of this approach, the NHS South West region has pioneered an independent sector and NHS partnership CDC network across the region, including 5 independent sector-led CDCs and a fleet of independent sector mobile units using a managed clinical service model approach.

The CDC programme is providing a good example of the potential for the NHS to increase collaboration with the independent sector in increasing diagnostic and other capacity across England, drawing on the experience and innovation that exists in ISPs.

Furthermore, as of 23 March 2023, NHS England has launched a diagnostic service within DMAS that enables every NHS provider to request additional capacity from the independent sector and other NHS providers across a wide range of diagnostic testing.

The NHS and DHSC continue to explore opportunities for further independent sector involvement in the CDC programme and wider diagnostic services.

Actions

The taskforce and the organisations represented on it are taking action on practical steps to enable more sustainable collaboration between the NHS and the independent sector, including:

• NHS England are developing the NHS Digital Staff Passport, which will go live in December 2023. This will enable a verified virtual record of a doctor’s training and occupational health records – reducing the administrative burden of moving between providers

• the ‘doctors in training’ group comprising the Independent Healthcare Providers Network (IHPN), NHS England and the royal colleges will continue to ensure barriers to junior doctor movement are minimised especially where ISPs undertake a significant volume of NHS work

• IHPN will publish an evaluation of apprenticeship schemes by October 2023 across ISPs following the conclusion of the taskforce

• IHPN will conduct a benchmarking exercise by October 2023 to measure how much training is being undertaken in the sector and to publish this information with a view to demonstrating the ongoing progress which is being made. This will then be conducted annually

• NHS England will build on the experience of CDCs by developing a mechanism to track, monitor and evaluate independent sector’s impact on the long-term NHS capacity landscape

• NHS England will publish best practice case studies on NHS and independent sector collaboration by August 2023 to boost outpatient, diagnostic and treatment provision to inform planning for future years

Delivering this plan and going further

The delivery of the actions within this report will complement the ongoing implementation of the delivery plan for tackling the COVID-19 backlog of elective care.

Actions

To maintain momentum, material improvements have been introduced in how data and evaluation are used across the NHS and independent sector to monitor specific changes in ISP use, as well as the outcomes of care:

• NHS England is publishing regular data on independent sector use as part of a single data set from July 2023, showing the independent sector’s contribution to tackling the backlog. This will also help to ensure that independent sector activity is additional rather than displaced NHS activity
• NHS England is internally tracking year-on-year changes in activity across all specialisms including cancer as part of work in NHS systems and independent sector providers to prioritise the commissioning and delivery of a more diverse range of services from July 2023
• NHS England will update guidance to providers to include a validated referral source in the weekly management information collection by August 2023. This will show if independent sector referrals are coming through referring primary care professionals or directly from providers

Following the conclusion of the taskforce at the end of March 2023, the focus has turned to delivery and putting these actions into practice, with appointees invited to convene after 6 months to review progress.

Annex A: summary of actions

Empowering patients to exercise their right to choice – overcoming data, technological, information, and knowledge barriers to patients realising their right to choose where they receive their care. Actions include:

• NHS England expanded the My Planned Care service to enable patients to compare waiting times across all providers within a specialty
• NHS England will continue developing waiting time information over 2023 to improve accuracy, and ensure referring primary care professionals and patients have access to the same information
• NHS England has delivered improvements to the e-RS so referrers can see all potential healthcare providers in a single menu that can be sorted by waiting times
• the NHS is making further changes to make it easier for patients to manage their appointments by rolling out patient engagement portals across England. Once the portals are established and linked up with the NHS App, patients will be able view their appointments and request to change to their appointment
• NHS England are developing a patient-initiated DMAS which will enable patients to request to move provider. From the end of October 2023, all patients who have waited more than 40 weeks without having had their first outpatient appointment will be able to initiate a request to transfer to another provider
• DHSC and NHS England will run a patient-facing comms campaign from August 2023 to ensure patients know about their right to choose and how to exercise it
• DHSC, with NHS England support, will update the NHS Choice Framework to help patients understand the choices available to them in the NHS. The updated framework will be published in August 2023
• NHS England is working to establish a baseline position for how many patients are currently accessing choice

Delivering a post-pandemic recovery – overcoming obstacles to providers offering healthcare services, ensuring payment mechanisms promote the right incentives, and overcoming barriers to transferring activity to the independent sector. Actions include:

• in January 2023, NHS England set out a clear priority to include ISPs in local plans to tackle the backlog within its 2023 to 2024 priorities and operational planning guidance
• the NHS guidance also set out a return to paying according to the amount of elective activity delivered to allow ICBs to move elective activity across providers, including to independent sector providers
• lessons learned from the long waits projects have been taken forward as part of NHS England’s independent sector programme
• NHS England published new guidance in July 2023 that clarifies NHS England’s role in ensuring commissioners operate in compliance with their obligations related to patient choice, in line with current legislation
• subject to the Parliamentary timetable, DHSC aim to revise patient choice legislation and establish the PSR in 2023
• NHS England will update NHS Choice guidance in line with revised regulations on patient choice in 2023
• DHSC and NHS England intend to introduce an independent panel that will review compliance with patient choice and PSR requirements

Enabling a longer term system sustainability – ensuring the NHS and independent sector work together to ensure they both have access to a sustainable workforce and facilities both now and in the future. Actions include:

• NHS England is developing the NHS Digital Staff Passport, which will go live in December 2023
• the doctors in training group comprising the IHPN, NHS England and the Royal Colleges will continue to ensure barriers to junior doctor movement are minimised
• IHPN will publish an evaluation of apprenticeship schemes by October 2023 across ISPs following the conclusion of the taskforce
• IHPN will conduct a benchmarking exercise by October 2023 to measure how much training is being undertaken in the sector. This will then be conducted annually
• NHS England will build on the experience of CDCs by developing a mechanism to track, monitor and evaluate independent sector’s impact on the long–term NHS capacity landscape
• NHS England will publish best practice case studies on NHS and independent sector collaboration by August 2023

Delivering on this work and going further – the material steps that will support delivery of the recommendations in the report, and improve how data and evaluation is used across the NHS and independent sector. Actions include:

• NHS England is publishing regular data on independent sector use as part of a single data set from July 2023
• NHS England is internally tracking year-on-year changes in activity across all specialisms, including cancer, as part of work in NHS systems and independent sector providers to prioritise the commissioning and delivery of a more diverse range of services by July 2023
• NHS England will update guidance to providers to include a validated referral source in the weekly management information collection by August 2023

Annex B: taskforce appointees

• Minister of State, Will Quince MP (Chair), DHSC

• Elin Jones, Director of Elective Recovery, DHSC

• Robert Ede, Ministerial Adviser, DHSC

• Bill Morgan, Healthcare Adviser, Prime Minister’s Office, 10 Downing Street

• Sir Jim Mackey, National Director of Elective Recovery, NHS England

• Prof Tim Briggs, Chair of the GIRFT Programme and National Director of Clinical Improvement and Elective Recovery, NHS England

• Bernadette Bluhm, Director of Elective Operations and Delivery, NHS England

• Dr Roberto Tamsanguan, Clinical Director for Tower Hamlets and Clinical Adviser, NHS England

• Mark Brassington, Regional Director of Performance and Improvement, NHS England Midlands

• Cara Charles-Barks, Chief Executive, Royal United Hospitals Bath

• David Hare, Chief Executive, Independent Healthcare Provider Network

• Dr Paul Manning, NHS Consultant Surgeon and Chief Medical Officer, Circle Healthcare

• Darshak Shah, co-founder and Non-Executive Director, Newmedica

• Dr Elaine Kelly, Head of Economics Research, REAL Centre team

• Rachel Power, Chief Executive, The Patients Association

• Mandy Nagra, Chief Delivery Officer, Birmingham and Solihull Integrated Care System

• Dr Bahman Nedjat-Shokouhi, Chief Executive Officer, Medefer

1. NHS England. Statistics, Consultant–led Referral to Treatment Waiting Times Data 2022–23. When including independent sector diagnostics tests recorded within NHS trusts, the figure is closer to 15%. ↩