‘I’m absolutely convinced the NHS will still be a huge success in 75 years time, it'll just be something that we can’t recognise now,’ says Sir Jim Mackey.
The challenge of elective recovery does not just lay in planning, the NHS also needs to get enough energy, system momentum, investment, and hearts and minds behind it to actually get the service back on its feet. Crucially, they only have one shot.
Throughout the initial planning period, Sir Jim found that ‘every few months it felt like there was a new theme’. Each time a plan was almost agreed on, the world threw another curveball. The past few years have brought a mix of challenges including infection prevention and control, rising demand, and increasingly complex care creating the logistical challenge of freeing up hospital beds.
Compounded by industrial action and a tough winter in urgent care, the service has been under unprecedented pressure. Despite these challenging odds, the NHS has seen significant progress towards key milestones that Sir Jim Mackey is keen to highlight:
‘We have made massive progress since the start of the year on our long wait ambitions and the virtual elimination of 78-week waits this year. [This was achieved] through a combination of using the things that we’ve learnt, deployed, and have found worked well so far, but also recognising that we're going to build something that’s more sustainable in the future.’
A System-Wide Shakeup
‘There's a need to refresh the outpatient model because it's been in place for over 100 years - there’s better technology in place now that can enable it to happen, we need good data to support it, and there's an awful lot going into that now.’
‘This helps us - as well as clicking through the different milestones on long wait reduction - to try and make a big leap for a future that makes it all more sustainable, modernised, and brought in line with the way we live the rest of our lives.’
This desire for a modern and tech-driven NHS is shared by many, but making it a reality is far from simple. For Sir Jim, the priorities are clear: ‘First of all, there is pretty strong agreement that outpatient care needs to transform.’ From patient groups, clinical groups, and operational and managerial colleagues, there’s a recognition of the need for change - and a will to implement it.
‘I think one of the key drivers in all of this is data availability, accuracy of data sharing, good practice, and informing the public of what their choices are. The patient portals now being deployed in the NHS and giving patients more ownership and control are big game changers.’ This change is underway in the NHS, but the size of the system is a challenge. 100 million outpatients are seen every year, so we need more than good intentions; ‘trying to break it up into manageable chunks for people to actually feel like progress is happening - and see what happens as a result of our effort - is a big part of this next phase.'
Beyond the enormity of the challenge
As well as the significant challenges of scale, ‘there's a lot of natural human resistance,’ comments Sir Jim.
‘If you're a clinician in a specialty that looks after patients with long-term conditions, a lot of the patients that we’re trying to move [towards digital access] are people you might have a 20-year relationship with. There’s a really positive patient-clinician bond there that we need to not disturb.’ There will also, at times, be anxiety and a natural hesitancy from patients about whether they can continue to have the access they need.
‘I think, really, we've got a lot of good intelligence now to see what's actually going on and where the barriers are. But it will be one of those things where it will feel slow until, eventually, we're at a tipping point.’ The challenge is to reach that tipping point in time.
Stemming the impact of industrial action
Industrial action has had a huge impact on patients through a significant number of lost appointments and large-scale rescheduling. ‘There's no doubt that when you're in a period where this is happening every few weeks it disrupts the efficiency, but I think people have managed to find lots of ways to mitigate that as much as possible.’
‘One of the things we learnt early on was to run cancellations as late as possible.' Sir Jim noted that a lot of cancelled activity in the first round of industrial action could have actually been carried out when more people came into work than initially expected. Cancelling an appointment is not a decision to take lightly; ‘this may sound really obvious, but every time you take something down you've got to replace it.’
As a result ‘we’ve learned to be very agile,’ trialling solutions such as keeping appointment slots open and calling patients to confirm - or cancel - on the day. The crucial part of this is transparent communication with the patient, and agreeing the process with them beforehand as opposed to sudden cancellation at the eleventh hour.
Stabilising waiting lists
Scepticism around tackling the elective backlog is a familiar refrain, and it’s one that Sir Jim Mackey would like to challenge. ‘I wouldn't accept that we haven’t made real progress,’ he commented. ‘We virtually eliminated two-year waits last summer - we now have about three hundred or so two-year waits out of a waiting list of around 7.4 million. We have around 10,000 18-month waits, which would have been about five or six at the end of March if it hadn’t been for industrial action.’
Even amidst industrial action, significant progress is being made:
‘Before Easter, there was strong evidence that the waiting list has stabilised at about 7 million about eighteen months - and a couple of million patients - ahead of time. It's grown a little bit through industrial action rather than underlying causes. I think, when we stand back from that, that's actually a pretty big achievement.’
‘We obviously want everything to move more quickly, but I think we also have to be reasonable and think about what the NHS has been through and what the NHS has achieved not just in general, but also juggling industrial action with pressures in urgent care, primary care, social care, you name it.’
‘There's a real danger that we're talking about the NHS as though it's the only part of society that hasn’t coped with the last few years,’ but in reality, our whole world is still reeling from the fallout of Covid, Brexit, the ongoing cost of living crisis, and the war in Ukraine. ‘I think we have to recognise what the NHS has managed to deliver in a difficult period; in lots of ways, the way it is recovering is an exemplar for the other parts of life.’
Pushing Forward with ICBs
The effectiveness of ICBs has been a point of debate, but Sir Jim Mackey notes that we must remember that this new part of our infrastructure has only completed a full year of existence. There is an ongoing process of identifying what is the remit of ICBs, what is the responsibility of provider collaboratives, and what are simply individual institutional capabilities. This has ‘been an unusually complicated process and crystallising how it actually works will take time.’
To ensure that enthusiasm around ICBs translates into real change we must continually ask the important questions: ‘What's this doing for the population? What's it doing for our staff? What's it doing for our patients?’ We must also be clear about what it is we’re trying to achieve, how we're going to measure that, and what the support is.
‘Some of the things that will begin at an ICB level will have an impact in 10 years' time,’ notes Sir Jim. ‘They’re not immediate operational things where you can decide on a plan and see what happens tomorrow. We need to be sensible and proportionate about the length of time things are going to take. At an ICB level, we’re really setting our ambition to give kids a better chance in certain populations using population health data - that's not going to happen next week.’
75 Years Down, 75 More to Go?
As the NHS celebrated its 75th birthday, we challenged Sir Jim to imagine where he sees the NHS in 75 years. ‘75 years is a long time - just five years ago, we hadn’t heard of COVID!
Looking forward is a combination of celebrating what the NHS has achieved and what its strengths have been, especially the way it's embedded in British society. It's a real jewel in the crown and people really cherish it. We're a big employer, and everyone is affected by the NHS in some way.’
‘But what we know is that we've got some really big changes ahead of us and we are really going to have to adapt to change to be able to make it sustainable in the future. The thing that really gives me hope is the way the service changed and adapted in an unbelievable way during COVID.’ This ability - and willingness - to change in the face of unprecedented challenges is what has made the NHS so resilient over the past 75 years, and it bodes well for the future despite the challenges ahead.
‘I’m absolutely convinced the NHS will still be a huge success in 75 years time, it'll just be something that we can’t recognise now.’