IF the NHS were a patient recovering from Covid, what stage would it be at: ready for discharge home, rehabilitation, or still on life support?

Almost a year ago, in August 2021, the Scottish Government unveiled its five-year recovery plan with ambitious goals to ramp up capacity and clear the waiting list backlogs which have spiralled during the pandemic.

On Wednesday, Health Secretary Humza Yousaf pledged that, by the end of September - in just 12 weeks' time - two-year waits for inpatient and day case treatment “in most specialties” will be eradicated.

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To achieve this, clinical prioritisation guidelines are being revised so that patients who have already been waiting over two years for operations can be fast-tracked, for example by being referred to another health board area for surgery.

There is a mountain to climb, however.

As of March 31 this year, there were 10,613 patients - including almost 3000 languishing on the orthopaedic list for hip, knee and joint replacements - who had already been waiting two-plus years for a hospital procedure.

Before the pandemic, such delays were virtually unheard of: in March 2020, only 98 patients had been waiting over two years, while in March 2013 not one single patient on the inpatient and day case list had been waiting longer than 28 weeks.

That tells us that problems had been building up for years, only to be turbo-charged by Covid.

Worryingly, even restoring the NHS to pre-pandemic activity is proving to be a struggle thanks to a never-ending onslaught of Omicron waves.

Back in 2013, there was no one on an inpatient or day case list who had been waiting more than 28 weeks for their procedure. By the end of March this year, more than 10,600 people had been waiting over two yearsTotal hospital admission numbers have been broadly similar since April 2021, and remain below pre-pandemic levels

Despite the emphasis on “NHS recovery”, the total number of hospital admissions (elective and emergency combined) in the week ending June 26 remained 11 per cent below pre-pandemic levels, compared to 6% below for the same week in 2021.

The number of elective procedures carried out during March, April and May this year - 56,555 - is up by just 7% compared to the same period last year, and remains 29% below 2019 levels.

Back in 2013, there was no one on an inpatient or day case list who had been waiting more than 28 weeks for their procedure. By the end of March this year, more than 10,600 people had been waiting over two yearsThe number of elective procedures being carried out has been similar from March 2021 onwards

Yet the Government has set a target that the total number of day case/inpatient procedures performed by NHS Scotland in 2022/23 should actually exceed pre-pandemic numbers by some 27,500.

Given the ongoing disruption being caused by Covid, and mounting fears that a flu resurgence in winter could be an even bigger obstacle, it is difficult to see how this can be achieved.

It is also worth noting that activity was stagnating long before Covid came along.

Between 2013 to 2015, an average of 83,065 patients were seen by the NHS for inpatient or day case treatment in the first quarter of each year (between January and the end of March).

For the same quarter, from 2017 to 2019 - pre-pandemic - this had fallen to 71,772.

At a time when demand from an ageing population was growing, why would the number of patients being seen have declined by 13.6%?

One clue is staffing.

By the end of March this year, the NHS Scotland workforce - excluding GPs and high street dentists - was at a record high of nearly 157,000 (counted as whole-time equivalent to adjust for those working part-time).

But that only tells part of the story, because staffing levels have simply not kept pace with demand.

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Between March 2015 and March 2022, as NHS staffing grew by 14%, the total number of vacancies for doctors, nurses, midwives and allied health professionals (such as physiotherapists and psychologists) ballooned by 163%, from less than 3000 to nearly 8000.

That reflects a combination of jobs being created but going unfilled, as well as staff leaving, retiring, cutting their hours, or quitting the NHS to take better paid and more flexible jobs as agency nurses and locums.

Nurse and midwife vacancies were 72% higher by the end of March this year than they had been in December 2019.

Back in 2013, there was no one on an inpatient or day case list who had been waiting more than 28 weeks for their procedure. By the end of March this year, more than 10,600 people had been waiting over two yearsHigh Covid rates in the community are continuing to cause disruption for the NHS through staff absences and loss of beds

The BMA also insists that official statistics massively underestimate the true shortfall in consultants because they only count those vacancies which have actually been advertised.

Meanwhile, there is huge alarm that nothing is being done to stem a UK-wide exodus of senior clinicians driven into early retirement by punitive pension taxes which effectively charge them for going to work.

A report by the Royal College of Radiologists in June forecast that, by 2026, Scotland is heading for a 30% shortfall in radiologists (compared to 23% now).

For clinical oncologists, the shortfall is expected to climb from 13% to 21%.

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This does not bode well for addressing challenges in cancer care.

The 62-day target stipulates that 95% of cancer patients should wait no longer than 62 days between the initial "referral with an urgent suspicion of cancer" and commencing treatment.

This was last met at the end of 2012 and dipped to a record low in the first quarter of 2022, when fewer than 77% of patients were seen in the timeframe.

The bottleneck occurs at the diagnosis stage. This is nothing new, but has been considerably worsened by Covid.

At the end of June 2019, there were 4,356 patients on lists for a key diagnostic test (MRI, CT scans, colonoscopies etc) who had been waiting over 92 days - at that time, an unusually long wait.

By the end of March this year, that figure was 44,088, including more than 5000 patients waiting over a year.

It is clear even from A&E gridlock alone that we are still a long way from squaring the circle between "living with Covid" in the community and enabling the NHS to live with it, as staff absences due to the virus (both in hospitals and social care) and bed losses linked to requirements to keep Covid and non-Covid patients in separate wards continue to squeeze capacity.

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In the four weeks to June 26, over 3,100 patients spent more than 12 hours in A&E, simply because there was nowhere else in the system for them to go.

Over the same four-week period in 2019, that figure was 201; back in 2015, it was 51.

The NHS turned 74 this week - not quite old enough for a Spring booster.

But if age alone didn't make it vulnerable, Covid on top on years of accumulated frailties and malaise has left it critically endangered.