Arriving at the end of July, the letter to systems setting out the third phase of the NHS response to Covid-19 was the first time expectations for recovery and restoration were prescribed. Significant and rapid acceleration of non-Covid activity over the course of the next three months made up a major part of these priorities.

The phase 3 letter sets out the expectation that trusts and systems should deliver at least 80% of their previous year’s activity for both overnight electives and for outpatient/day case procedures in September, rising to 90% in October and aiming for 70% in August. It goes on to recognise that this requires a return to at least 90% of the previous year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100% by October. Finally, there is a need to reach 100% of the previous year’s activity for first outpatient attendances and follow-ups from September and through the balance of the year. Based on the latest national figures (June 2020 HES, specific acute) there is a significant gap to make up to achieve the target milestones, with day case and ordinary admissions both sitting in June at around 45% of September 2019 levels and first outpatient attendance and subsequent outpatient attendance at around 62% and 72% respectively.

As they stand, the current expectations are not set in terms of either a target RTT performance percentage or waiting list size, but in terms of plain activity. The removal of the complexity of planning to achieve a performance standard and/or waiting list size target in this phase of the NHS’s recovery is a good thing, activity is the easiest unit of measurement to work with. This represents a shift away from previous recovery drives and perhaps demonstrates a very necessary injection of pragmatism considering the scale of the challenge. That said, within the detail of the planning returns, there is an expectation to provide total RTT waiting list figures and over 52 week waiter numbers on a monthly basis. So, when planning, it will still be important to isolate clock stopping activity from other planned activity. This will need doing at quite a granular level when determining each set of actions required and their impact.

The pre-existing prioritisation principles for elective care remain unchanged, namely high clinical priority (urgents) first, followed by the longest waiters in RTT pathway chronological terms.  As a result, there are two different goals that need to be considered equally important throughout the planning phase and beyond: seeing and treating enough people (to meet 2019 levels) and seeing and treating the right people (to limit the growth of long waiters and ensure a clinically appropriate distribution). What each clinical service takes to understand as a clinical priority is of course an emerging concept in late summer 2020.

So where to start? Despite the 21^st September deadline for the submission of system plans, this will inevitably be an iterative process. Providers may wish to prioritise understanding where (in which specialties) these milestone activity targets are more and less achievable considering: the starting point (current levels of activity achieved throughout phase 2) and the nature and complexity of any extraordinary measures necessary to meet existing and required levels of activity – i.e. understand the barriers at an early stage. Those barriers may also be helpfully expressed in clear and consistent categories allowing for the task of meeting their various challenges to be distributed appropriately across different parts of the system: e.g. in terms of estate restraints, staffing, clinical pathway barriers etc.

There is a clear direction in the phase 3 letter to make use of alternative options for generating capacity, in some cases these efforts will aim to free up more traditional capacity options and in others to replace the face-to-face appointments which provide an ongoing risk to be managed in relation to the virus. Systems will want to work as a priority to develop local protocols and identify appropriate opportunities for increased use of advice and guidance routes to prevent onward referrals and ease the pressure as well as implementation of patient initiated follow-up (PIFU) and expansion of telephone/video OPAs in order to provide capacity release elsewhere in the service. On top of this, maintaining and going further on independent sector capacity utilisation from both an outsourcing and insourcing perspective will remain key.

Communication with patients will be paramount; there is clear expectation that those whose treatment has been affected by the pandemic are contacted and informed of next steps. This will take a significant coordination between primary and secondary care and establishing how to go about this will be another early priority. Providers may also wish to use the opportunity of contacting patients to review their clinical circumstances and implement different options for their onward pathway depending on the outcome.

One thing that is clear is that the need for accurate and accessible data will be essential at every turn. From understanding the detail of last year’s activity figures, to the ability and capacity to deliver those levels in the coming weeks; from effective clinical prioritisation to understanding the capability for outsourcing and alternative capacity options; and from identifying and reassuring those patients who have been delayed to the waiting list management techniques required to make a sustainable impact on an already fundamentally challenged sector of the NHS.

Thinking ahead, perhaps to “Phase 4”, the ask ahead of November for elective care is described as a ‘window of opportunity’ and so the assumption remains that there is a distinct possibility of a suspension of elective activity again over winter (this would be consistent with the last few winters irrespective of the pandemic). For now, success appears to be returning to pre-Covid levels of activity for a time, but two sizeable problems remain when we recall that September 2019 levels of activity were not sufficient to keep pace with demand twelve months ago. Firstly, how to make headway into the additional backlog caused by successive months of scaled back elective activity and secondly, how to meaningfully return to the task of taking a full and complete view of the scale of the problem for elective care performance, a task that was arguably overdue this time last year.

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