The NHS is facing one of the biggest crises in its modern history, with a toxic cocktail of problems having an unprecedented impact on the service. Hospital waiting lists are at a record high1 due to the backlog created during the COVID-19 pandemic and a lack of resources.
The health service is also experiencing major staffing shortages2 and wider pressures placed on the services by a social care crisis that is on its knees after the pandemic. Not to mention that NHS England is also going through the biggest structure re-organisation in a decade3 following the Heart and Care Act’s introduction of integrated care systems. To say this is a political headache for the next occupant of number 10 would be an understatement. One of the key health challenges they will face is restoring public confidence in the NHS at a time of dwindling satisfaction.
The former Chancellor of the Exchequer, Nigel Lawson, once famously said that the NHS is the closest thing the British people have to a national religion.4 However, recent events have begun to test their faith. Public perceptions of the NHS have plummeted and are now at their lowest level since 1997.5 Overall satisfaction with the NHS has fallen an unprecedented 17% since 2020.5
What are we to make of this remarkable change of heart? After all, the NHS was pivotal to the Government’s messaging during the height of the COVID-19 pandemic. The memorable message “stay home, protect the NHS, and save lives” harnessed the emotional power of people’s affection for the NHS to provide a compelling reason for people to follow the COVID-19 restrictions.
Whilst the British public had genuine gratitude and admiration for the health care workers who helped us through the pandemic, the reality of the challenges facing the health service in a post-pandemic world seems to have soured public sentiment.
The public is still overwhelmingly in favour of the NHS’ founding principles that it is free, universal and primarily funded through taxation; their main gripes relate to long waiting times, NHS staff shortages and inadequate government funding.5
The NHS’ dedicated staff have supported the nation through the biggest health crisis in our modern history. Whilst no one doubts NHS staff’s commitment and hard work, they often lack the necessary tools and resources to do their job.
A recent select committee report confirmed what people working in the NHS had known for some time: that there are widespread staffing shortages across all service areas. The NHS is the largest employer in England with 1.2 full-time staff;6 however, it currently has vacancies of at least 110,000 across all NHS Trusts, with many more in primary care.7
The reasons for these shortages are complex and not easily summarised. Key driving factors include failure to effectively forward plan and train additional staff. The previous Secretary of State for Health and Social Care publicly acknowledged that the manifesto pledges 6,000 more GPs in England by 2024/25. The NHS target to fund 26,000 additional roles in 2023/4 is unlikely to be achieved within the original timescales.6 England has a lower proportion of doctors relative to the population than the Organisation of Economic Co-operation and Development (OECD) EU average8. The OECD EU average is 3.9 doctors per 1,00 people. England has just 2.9, far lower than Germany at 4.3.8 There is also an issue with the ageing nature of the healthcare workforce. Research from the BMA suggests that 13% of secondary care doctors and 18% of GPs will retire in the next ten years, which could mean a loss of over 25,000 doctors.8
A recent survey of NHS Trusts leaders found that almost all trust leaders (97%) say that current workforce shortages are having a serious and detrimental impact on services, and 98% say that shortages will slow down progress in tackling the growing care backlog.9 The overwhelming majority (97%) say the lack of certainty over workforce supply may impact the ability of the NHS to retain staff.9 These findings make for uncomfortable reading and pose a series of questions about the day-to-day running of the health service. The demand for care outstripping supply and resources also presents a major hurdle in tackling the critical care backlog.
The surging demand for healthcare services during the pandemic and the shortages of resources created a significant backlog of treatment and a lengthy waiting list for care. One of the features of the NHS is that it runs close to capacity most of the time as it has lower levels of staffing per patient, bed space and ICU capacity compared to its European neighbours.10
The care normally delivered was severely disrupted during the pandemic, meaning more patients were waiting for treatment. Clearing the backlog won’t be easy and could take years.
As with all these issues, care backlogs are not new, in February 2020, there were already 4.43 million people on critical care waiting lists.11 However, there can be no doubt that the pandemic has exacerbated the scale of the problem.
The latest analysis from the BMA shows that for June 2022, a record of over 6.73 million people were waiting for treatment.11 The number of patients waiting over a year for treatment is 7 times higher than a year ago.11 There are also 2.54 million patients waiting over 18 weeks for treatment.11 It is also important to remember that the waiting list represents the visible backlog; there is also a hidden underlying backlog that the official figures don’t show. Many people required care during the pandemic but did not choose to seek help to ease pressure on the health service during the pandemic, and had referrals and treatment cancelled that have not subsequently been re-arranged. Several crucial targets are also missed in the NHS, especially in emergency care and cancer treatment.
The NHS has a very target-driven culture, but the ongoing strains on the health service have prevented flagship performance goals from being met. The NHS has a target that a specialist consultant should see 90% of patients with suspected cancer within two weeks of an urgent referral.11 The current figure is just 77%, well below target and suggests serious issues with capacity and investment in the system.11 This is even though GP referrals have risen above pre-pandemic levels.
Accident and emergency services are also under increasing pressure. The target of people being seen within four hours was already being missed before the pandemic. In July 2022, over 29,000 people had a 12-hour plus wait in A&E.11 Although people have been attending less since the pandemic, demand remains very high, with a total of 2.16 million admissions and attendances in July 2022.11
The challenge of fixing our broken social care system is a political conundrum that successive Governments have sought to solve, but none have succeeded. We are over ten years on from the landmark Dilnot report, which recommended capping the overall cost of care people pay over their lifetime of £35,000 to reduce the crippling financial burden many families experience in care costs.12
Sadly, things haven’t moved significantly forward. Former Prime Minister Theresa May attempted to reform the social care funding system by changing the threshold by which people should start paying for their care from £23,250 to £100,00013, but this would include the value of their property.13 This effectively meant that people would be forced to sell their homes to cover the cost of care. The policy was dubbed the “dementia tax” by its critics and was swiftly dropped due to the political backlash.
At present, the social care system faces a set of major challenges. Chronic underfunding is a particularly important issue; the funding for local authorities has been cut by 55% between 2010/11 and 2019/202.14 These spending reductions have disproportionately impacted the poorest areas of the country. Whilst a social care levy has now been introduced for local authorities to help fund social care, most of the money is not ringfenced specifically for social care and is not expected to raise the level of funding required.14
There are also serious staffing issues. Severe staff shortages mean there are not enough staff to care for people’s needs, with projections indicating that vacancies in adult social care could rise to almost 500,000 by the end of 2030.15 The social care workforce receives the lowest wages of nearly every sector in the UK, with almost a quarter (24%) of the social care workforce employed on zero-hour contracts, rising to 41% in London.15 Staff shortages in the social care system have resulted in a sharp increase in the number of people providing unpaid care to loved ones. Approximately 350,000 young people aged 16–25 in England and Wales provide unpaid care.15
With energy prices soaring and the economy predicted to fall into recession later in the year, tackling Britain’s economic problems will inevitably be the number one priority in the Prime Minister’s political in-tray.
However, confronting the NHS crisis cannot be avoided for long. Rising inflation will dilute the efficacy of the Government’s existing spending commitments for the NHS and almost certainly result in calls for additional public investment beyond the existing settlement. Whilst NHS England is undergoing a major structural change with the introduction of integrated care systems, systemic operational changes alone will not be sufficient to solve the scale of the health service crisis.
Increasing the capacity and resources through the health and social care system is needed to match the scale of the challenge, but this will be difficult to deliver in practice due to the constrained fiscal settlement. The prospect of a looming winter health crisis with seasonal flu and rising COVID-19 cases set to put additional pressure on already strained resources will inevitably place health policy higher up the political agenda. Let’s hope Downing Street’s next resident has the right cure for our nation’s ills.