One in 20 patients now waiting over two years for operations on NHS Scotland

One of biggest challenges lies in the scale of the treatment backlog accumulated over the past two years as "non-urgent" elective operations were repeatedly paused, with figures this week revealing that the total number of people on waiting lists for inpatient, day case and outpatient care combined has reached 539,000 - up from 362,000 in December 2019.

These statistics mask the extent to which excessively long waits for elective procedures have spiralled, however.

As of December 2021, 27,115 people on inpatient and day case lists had been waiting over a year - up from 1,345 in December 2019.

Waiting times in excess of two years have gone from something that was virtually unheard of before the pandemic to a problem affecting almost one in 20 patients on the inpatient and day case list.

In December 2019, just 150 patients on the list had been waiting over two years; by December 2021 this had ballooned to 5,300.

The Scottish Government has set a target to ramp up inpatient and day case activity to 20 per cent above pre-pandemic levels by 2026 through a network of nine National Treatment Centres - dedicated elective hubs - with an extra 1,500 staff to run them.

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However, Audit Scotland has cast doubt on the plan - calling it "stretching and difficult to deliver" in the face of long-standing recruitment struggles, a lack of "robust and reliable" workforce data which means genuine staffing requirements may be underestimated, and uncertainty over future demand on the NHS.

In particular, the watchdog is concerned that current backlogs do not necessarily reflect the true scale of "unmet need" during the pandemic - from undiagnosed cancers to fractured mental health - which could yet pile further pressure on the system.

The total number of NHS hospital admissions in Scotland remains significantly below the pre-pandemic average

It is a concern echoed by Mark Dayan, head of public affairs for one of the UK's leading health think tanks, Nuffield Trust.

"In both Scotland and England, if you look at the amount that the lists have grown it still doesn't fully match the number of patients who weren't treated during the pandemic," said Mr Dayan.

"The Scottish NHS is still operating a long way behind its pre-Covid capacity, so in that sense there are still patients who seem not to be getting treated who would have been before.

"What nobody knows is, the extent to which they're coming back - and the extent to which it will be possible to increase the capacity to do operations."

The most up-to-date available figures, for January 23, indicate that the total number of hospital admissions in Scotland - emergency and elective combined - remained 19% lower than pre-pandemic averages.

Pessimistic clinicians draw a comparison with the early 1990s NHS, when lengthy waiting lists pre-New Labour investment drove an increased uptake in privately-funded healthcare.

When I qualified in 1987, NHS waiting times were often over two years. Peoples’ lives would be ruined while waiting and some would even die ‘on the list’. 35 years later and we’re back where we started…

— Dr Phil Hammond 💙 (@drphilhammond) February 9, 2022

Figures from the Private Healthcare Information Network (PHIN) show a 48% increase in the number of patients in Scotland self-funding inpatient procedures, from 2,300 in April to June 2019 to 3,400 during the same period in 2021.

The next set of data, up to September 2021, will be published on March 8.

Meanwhile, the Scottish Government also spent £34.7 million between April 2020 and December 2021 sending 7,256 NHS patients for operations at six private hospitals: Spire Murrayfield, Nuffield Glasgow, and BMI's Ross Hall, Albyn, Carrick Glen, and Kings Park hospitals.

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The "capacity utilisation arrangement" gives health boards access to operating theatres and beds in private hospitals without having to pay on a case-by-case basis. It also means that urgent patients can be treated in 'Covid-free' environments.

It has been used for cancer operations, such as breast, colorectal and prostate surgery, as well as orthopaedics, gynaecology, CT scans and diagnostic ultrasounds.

Mark Dayan stresses that this is "a fraction" of Scotland's overall health budget: 0.5% compared to the £12.2 billion spent by NHS England - 7% of its budget - on use of the independent sector last year.

"So far it's been on such a limited scale in Scotland that it's probably some way off raising systematic issues," he said, noting that over-reliance on the private sector to clear NHS backlogs could raise value-for-money issues as well as staffing conundrums.

"There's the risk that you are effectively paying the same doctors who already work in NHS hospitals to go to private hospitals instead to do the same thing," he said.

Leaked documents, revealed by the Herald in November, show a further £150m set aside to cover the cost of NHS procedures at private hospitals over the next five years.  

Asked to comment on its use of the private sector, a spokesman for the Scottish Government said it is "doing everything possible to ensure patients continue to be seen and treated based on their clinical urgency".

Professor Andrew Elder, president of the Royal College of Physicians Edinburgh, said it "is a concern" that waiting list pressures could drive more people to go private, but stressed he does not expect the pandemic to usher in any wholesale change in what is provided on the NHS or how it is funded.

"I don't believe there is a public appetite for a shift towards more private care," said Prof Elder.

What he would like to see - besides substantial increases in the NHS workforce and the capacity of facilities so that more patients can be seen - is a reversal in how the health service anticipates demand.

"I would like to see the way we plan care delivery to be focused on the winter months as the 'usual activity' months," said Prof Elder.

"What we do now is focus on the rest of the year and then have winter bed plans to deal with an inevitable 'surge'.

"It would be much better if we planned and resourced our health service around the worst of times - the winter months - and then worked out what to do with any spare capacity during the quieter months.

"That would be a more sensible way of going about things."

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A Scottish Government spokesman said the latest waiting list figures "cover the period when Scotland's NHS boards, hospitals and healthcare providers were required to change their normal way of working to manage their response to manage the Covid-19 response".

He added: "This inevitably had an impact on the volume of hospital activity and trends, with both inpatient and outpatient activity down compared with pre-pandemic levels.

"Activity continues to recover, although we are still not up to pre-pandemic levels and the NHS continues to be affected by Covid-19 related pressures.

"Our NHS Recovery Plan is backed by over £1 billion of targeted investment and work continues at pace to deliver the measures introduced through these plans.

“Staffing levels across NHS Scotland have also reached a new record high after an increase of over 7,500 whole time equivalent staff in the last year.

"We are also working with our partners to fill any vacant posts as quickly as possible.”