Elective Surgical Operations: Waiting Lists

Rachael Maskell Excerpts

Tuesday 20th April 2021 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

It is a pleasure to speak with you in the Chair this afternoon, Ms McVey. I extend my thanks to my hon. Friend the Member for Bootle (Peter Dowd), who opened the debate so well.

Once more the NHS has been pushed to its limits these past few months, and once more it has delivered an unprecedented response. Every single person working for the NHS has strained every sinew at every hour of every day and night to support as many people and save as many lives as they could. I know how staff in York’s NHS services have stretched their known capability, skill and knowledge, have extended their capacity to care and support, and have served our community without complaint or restraint. For that reason, I echo hon. Members who have said that those staff need to be justly rewarded with a well-overdue pay rise.

At York Teaching Hospital, 1,974 covid-19-positive patients were treated between September 2020 and the end of March 2021, in a very challenging clinical environment, where infection control measures tested staff and the system. The hospital is already a challenged site, and that experience indicates that conversations must commence on the future of the hospital estate in the city. It serves a growing population, and I hope that the Minister would clock that and be open to early discussions about how, over the next decade, we can develop plans to meet the health needs of our city. Already, year in, year out, over the winter crisis it is challenged, but covid-19 has really pushed it to its limits.

As the latest phase of the crisis abates, the next mountain must be conquered. The pressure it causes is relentless. Elective surgery, which was stood down at the beginning of the pandemic, continued through the rest of the period. However, we know that the number of cases has built up.

In York, the independent sector is used to provide some of the cancer care. Good cancer networks were built with the local establishment. It would be good if the Government would publish the amount they have spent on contracts with the independent sector throughout the pandemic. Has it been at cost or at an escalated cost to the state? We need that information so that we can understand the extent of the use of the independent sector and so that lessons can be learnt about the need for national contingency in public health facilities, and about how the private sector is drawn on and whether there are better models out there for procuring services.

While staff have had to be redeployed to respond to covid-19 and address clinical priorities, which is absolutely right, York managed to continue with its planned surgery through the national phase 3 elective services restoration period up until March 2021. It has done really well: it has delivered 96% of the planned elective in-patient activity—ordinary elective and day cases—and 108% of the planned out-patient activity. That equates to the delivery of nearly 3,000 ordinary electives, 36,000 day cases and nearly 400,000 out-patient appointments over the six-month period. That is an incredible feat, because of the constraints—indeed, due to the sharp rise in covid cases in York, particularly following the Christmas period, 564 elective procedures were delayed—but those figures dwarf into insignificance compared with the scale of what is needed now. Nationally, there is a reckoning that it could take about five years to clear the list. And of course the Minister is planning a reorganisation of health services in the midst of all that, which may have some implications. I trust that, in his response to the debate, he can say how that will be bridged.

As we went into the pandemic there were already significant backlogs in elective care, as a result of austerity measures—cuts—being applied to services. That has had its implications in York. We have a high level of recruitment and retention in York—the vacancy rate is just 6%—but clearly there are implications due to the rationing that was applied. As a result, our clinical commissioning group, Vale of York, has applied rationing to services, and I want to dwell on that for a moment, because many procedures are no longer available in the city, but also many involve restricted access for those with a BMI over 30—in the case of hip and knee replacement surgery, it has now been lifted to between 30 and 35—and for those who smoke. We know that that discriminates disproportionately against those who experience socioeconomic disadvantage.

I have debated the issue many times in the House, but to this day I hold, as does the Royal College of Surgeons, that these should be clinical decisions, and should not be based on algorithms to weigh the clinical risks. Of course we all understand that smoking and obesity lead to significantly higher risks in surgery, but far more needs to be done to support people with weight loss and smoking cessation. With surgery already significantly delayed because of the pandemic, to deny people access to a waiting list removes the clinical support that they need. They also need additional support to address the risk factors, not least because we know that, for many people who smoke or are overweight, that is the case because they are dealing with the presentation of their illness. For instance, they may not be able to exercise and mobilise because of pain, which makes them more susceptible to putting on weight—or perhaps because of stress and depression.

We need to see those issues addressed. We need to see far more intervention in the form of prevention at these points, but also it needs to be understood that people should not have to wait even longer for the elective surgery that they need. We know that, over the last 13 months, there has been a serious drop in the number of people accessing diagnostic tests, out-patient appointments and other clinical services, so they are set back even further. And of course it is not just those cohorts of patients who are affected; we know that the effects have gone to so many other areas. As we have heard, the impact on cancer diagnosis has been significant as well. We know that today there are many people living with undiagnosed conditions who will, when they present, have greater risk and poorer outcomes unless this situation is attended to urgently.

Altogether, the waiting lists could double—none of us knows exactly what will happen—for clinical procedures once community referrals catch up. That would just break the system and therefore we need to see more reparation being put in place. I know that the Minister is looking at those issues, but by the time someone receives surgery they are likely to have more complexities, more underlying health conditions and a poorer prognosis. As we have heard in the debate, approximately 18,000 people could also see premature mortality as a result of this. Of course, there is a significant loss to the economy, loss of jobs, loss of income, loss of lifestyle and loss of social connections, leading to mental health challenges as well. We need to make sure that during this period people have access to social prescribing and support for wider needs as well as their clinical needs.

Bearing that in mind, I want to dwell on the issue of diagnostic testing and the fact that attendance in some areas was already low. Will the Minister look at how specialist clinics and testing centres could be set up to screen the population? Just imagine if everyone who had their covid-19 vaccine had a thorough health MOT at the same time. That would have been transformative. I ask the Minister: what can be learned from the vaccine roll-out to be applied to screening programmes and out-patient backlogs, to ensure that the NHS gets back on track with the provision of services as they are needed, and perhaps as a model for the future, too?

I want to raise one more point before I return to elective surgery; that is the issue of research. Research has been significantly shelved over the last year. We know that surgical advances will assist by cutting waiting lists, reducing the risk of procedures and reducing the need for surgery in the first place. I urge the Minister to ensure that there is significant investment in clinical research, and that it is stepped up, not cut back.

To return to elective surgery directly, first, on staffing, we know that we have an ageing workforce and many of those who have stepped up this year are now stepping back. Other staff members are exhausted and, frankly, shattered by their experience over the past year, so we need to ensure that we see that growth in the workforce. I trust that NHS planning and commissioning of training will increase, and not just to ensure that we address the current crisis; that could be extended into the future shape of healthcare. We need to get those figures right and not see the famine and feast that we have often seen in the past—although I cannot quite remember a period of feast. However, we certainly need to see proper provision of staffing.

As for facilities, we cannot dismiss the fact that over the past decade, about 12,500 beds have disappeared from our NHS. Cuts do have consequences and we have paid heavily for that. This is an opportunity to look again at how we configure our services, both on the acute side and in rehabilitation, to ensure that facilities meet needs. All surgery carries risk, so critical care support must be available, but we also need to ensure that more is done to support rehabilitation centres of excellence. Often we see patients being discharged far too prematurely, only to bounce back into the system or not fare as well as they could have done, had they had more rehab before going home. I speak as a former physiotherapist, so obviously I am passionate about that, but it really does make a difference.

In the past, patients undergoing hip, knee and other orthopaedic procedures have often gone to rehabilitation centres. Some of those centres no longer exist. For us in our profession to put people through their paces and gain the confidence they need, we need to make sure that they have those skillsets before they are discharged home. That is because we know that when people get home, the biggest risk from those procedures is that they just sit in a chair and do not mobilise at the level that they could, which of course undoes all that has been achieved. What a waste of money, but also what a waste of opportunity in somebody’s life.

Community provision is still patchy and we know that the sufficiency is not there to give people the time and investment that they need in a domiciliary setting. Following elective surgery we need to optimise not just acute care but the rehabilitation process, and make sure that post-operative care is at an optimum.

Just before I close: as many have said, the numbers are significant, they have risen sharply and the situation requires significant investment. We are moving into a new model of health provision over the next period. It is really important that we get it right and that we ensure that, before the legislation comes to the House later this year, we have the levers in place to address this form of care, locally as well as nationally. It cannot be business as usual. The next crisis is here and needs as much attention as the Minister and his team have given to the last.