There is ‘limited evidence’ backing plans to tackle the elective backlog through GPs using ‘advice and guidance’ (A&G) services, the public spending watchdog has found.
A report published by the National Audit Office (NAO) today also warned against a reliance on passing more workload to GPs, pointing out that general practice itself is ‘under strain’.
In February, the Government set out its long-awaited elective recovery plan that stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.
A&G services involve GPs accessing specialist advice by telephone or IT platforms, rather than referring patients for a hospital investigation.
The new NAO report said that the elective recovery programme ‘relies’ on initiatives that ‘have potential’ but ‘limited evidence of effectiveness’ so far – including A&G, which involves GPs handling ‘many elective cases previously dealt with by hospital doctors’.
The NAO said: ‘NHSE has expanded some programmes because it judges them to be sufficiently promising, but there is currently only a limited evidence base for their effectiveness.
‘While these programmes may be based on good premises, NHSE will need to monitor carefully whether they are producing results in practice and build in proper evaluations as quickly as possible, being willing to re-direct resources as necessary to where they can have most impact.’
Setting out ‘ongoing risks’ to the elective recovery programme, the report pointed out that ‘several programmes in the recovery plan rely on additional effort by GPs, but the primary care system is itself under strain’.
It said: ‘The advice and guidance initiative might shift work from hospitals to GPs, but the GP workforce is under pressure too.
‘It is unclear whether GPs will be able to manage the additional workload that might result and whether databases across the country are capable of sharing and updating patient information efficiently to support this.’
It added that this extra workload for GPs comes at the same time as the workforce is decreasing – with the fully-qualified permanent GP workforce decreasing by 4% between 2017 and 2022.
NHS England told the NAO it is ‘monitoring the impact’ of A&G on the GP workforce as well as on secondary care.
A previous NAO report warned in December last year that the NHS needed to work out how GPs can help clear the elective care backlog without ‘overloading’ them.
However, the NAO found that NHS England is currently ahead of its targets to avoid referrals by providing GPs with specialist advice and guidance instead.
According to NHS data, GPs were already managing 22 patients out of every 100 they referred via A&G from April to June 2022, compared with their target of 16 out of 100.
The report added that NHS England ‘expects this to result in the avoidance of a referral in around half of cases’, so the patients are managed in primary care instead of hospitals.
The report’s other findings
- The move to ‘patient-initiated follow-ups’ (PIFU) also has ‘limited evidence’ for its effectiveness, with one review finding only around half of studies showed it reduced activity
- PIFU has also ‘causes concern among some clinicians and managers’ who say that it ‘could lead to increased patient harm’
- Surgical hubs and community diagnostic centres (CDCs) ‘can contribute to recovery’ but they ‘rely on adequate staffing’ and NHS England has ‘limited evidence’ on their ‘ability to continue operating when their host hospital or wider local area is under significant pressure’
- There has been a ‘positive’ increase in urgent GP referrals for suspected cancer but the NHS is ‘not treating all cancer patients in a timely way and people are experiencing record waits’
- NHS England’s claims that cancer referrals have ‘fully recovered’ may be ‘optimistic’
- 62% of ICSs (26 out of 42) ‘expect to miss’ NHS England’s elective activity target in 2022/23
- Meeting the elective recovery plan’s targets would ‘require a rate of growth not seen in recent times’ but even if the NHS does meet them, it will still fall ‘a long way short of the standards for waiting times set in NHS regulations’
- The plan promised a ‘fair recovery’ with a focus on reducing health inequalities but there is a ‘risk’ of these ‘worsening’
- Some of NHS England’s metrics for measuring recovery are ‘hard to understand and could be applied inconsistently’ or ‘illegitimately’, ‘masking the true progress the NHS is making and meaning it is harder to hold it to account’
- The funding allocated for recovering services has not kept pace with inflation
It concluded that NHS England should set up ‘independent evaluations of its major elective recovery programmes so that it is actively developing the evidence base for these initiatives’ before April 2023.
The report’s recommendations also included an NHS England review in the first quarter of 2023/24 of actions taken in 2022/23 to ‘assess progress’ as well as ‘unintended effects’ and a report in 2023/24 to ‘improve transparency’ on progress made, including an assessment of the results of increasing A&G.
It also said that the DHSC and NHSE should review the recovery plan’s progress in early 2023/24 and decide whether targets and funding allocations need adjusting.
NAO chief Gareth Davies said: ‘There are significant risks to the delivery of the plan to reduce long waits for elective and cancer care services by 2025.
‘The NHS faces workforce shortages and inflationary pressures, and it will need to be agile in responding as the results of different initiatives in the recovery programme emerge.’
Parliamentary public accounts committee (PAC) chair Meg Hillier added that the recovery programme is ‘very ambitious, reliant on innovative but relatively untested approaches, and already falling short of expectations’.
She said: ‘My committee previously warned the Government against over-optimistic plans. [It] faces a monumental challenge in fixing NHS backlogs.
‘Patients will continue to suffer the consequences if NHSE doesn’t act now to improve its management of the programme.’
Meanwhile, the BMA said the funding allocated for tackling the elective waiting list must be ‘urgently reviewed’, but that ‘no amount of money’ will clear the backlog ‘without the people to deliver it’.
BMA council deputy chair Dr Emma Runswick said: ‘As this report rightly points out, chronic pay erosion, punitive pension taxation, and dwindling staff morale are all contributing to a mass exodus of staff.
‘The suggestion that other parts of the NHS should pick up more work to chip away at the backlog shows a total disregard for the underlying problems in the system and how to go about fixing them.
Last month, the NHS waiting list hit an all-time high of seven million patients.