The NHS in crisis: where to now?

The beginning of 2023 has been dominated by more political change at the top of government, a cost-of-living crisis, a looming winter of strike action, and growing fears of a two-tier health system based on ability to pay.

The NHS under extreme pressure

In January more than a dozen trusts and ambulances services declared critical incidents, 500 people a week could be dying due to delays in emergency care. Further incidents and compromised quality of care could be likely in the coming months, said Matthew Taylor, chief executive of the NHS Confederation.

There are ongoing issues with hospital discharges, and over 12,000 medically fit patients are stuck in hospital, there is a decade-long lack of investment in capital, and an elective operations backlog, which continues to grow past 7 million people. The current situation in the NHS is unsustainable, both patients and staff are desperately trying to keep up with incredibly high levels of demand.

There are currently more than 130,000 vacancies in the health service, last year’s survey by the Royal College of Nursing found only ¼ of nursing shifts had the planned number of registered staff on duty, and most nurses reported that staffing levels on their last shift were not sufficient to meet the needs of patients.

Nurses are a particularly negative example with 47,496 vacancies or 11.9% of the total nursing workforce. A decline in real pay for nurses makes it harder to attract young people into nursing and to retain them in the profession in the long-term.

GP appointments and hospital emergency attendances are at record levels, neither flu nor Covid are likely to go away, so we will probably be living with both as a major source of sickness in the population.

Last December people who had heart attacks or strokes waited more than 1.5 hours on average for an ambulance to arrive, people in life-threatening conditions also waited longer than any time on record. And once people had been assessed, almost 55,000 people waited a further 12 hours in A&E to be admitted to hospital.

Time for a new approach

The debate around moving the NHS towards a preventative model has been going on for almost as long as the health service has existed – keeping people healthy makes sense, so they do not need to use the health service, and this will lead to better health outcomes.

Public health interventions are highly effective. A recent study by York University concluded that public health interventions are 3 to 4 times more productive than spending on healthcare delivery. Treating disease and not creating health has been our focus with only around 1% of day-to-day government spending going towards public health policies. The UK has some of the worst health outcomes and one of the unhealthiest populations in the OECD.

If we want to save the NHS, we need to spend relatively less on healthcare delivery and proportionally more on creating health, as health is a natural asset that drives social and economic prosperity.

Tim Gardner, senior policy Fellow at the Health Foundation said the recent data showed that the NHS is facing an emergency, but the roots of it lie in political choices made over the last decade, not the cold weather or seasonal flu. The pressures on the NHS result from a decade of under-investment in the NHS and other public services with the failure to address chronic staff shortages, raiding capital budgets, and a long-standing neglect of adult social care.

The priorities of NHS Long Term Plan 2019

In 2018, the government announced £20.5bn of additional funding for the NHS in England by 2023-24. Launched in January 2019, the NHS Long Term Plan set out priorities for how this money would be spent over the next ten years to improve and reform the NHS.

In 2019 Dr Jennifer Dixon, the Chief Executive of the Health Foundation, said:

“This is a pragmatic plan with an ambitious vision to improve NHS care but making it a reality will be extremely tough given growing pressures on services, widespread staff shortages and continued cuts to other parts of the health and care system.”

The Plan outlines a positive shift in the model of NHS care, towards an increasing focus on preventing people becoming ill in the first place, reducing avoidable demand, and narrowing unjust gaps in health between the best and worst off. This is particularly welcome given life expectancy improvements are stalling and health inequalities widening.

Patients support

• The plan sets out how the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting. 

Prevention

• The NHS will take to strengthen its contribution to prevention and health inequalities. Wider action on prevention will help people stay healthy and moderate demand on the NHS.

Workforce

• Workforce pressures will be tackled, and staff supported. The NHS is the biggest employer in Europe, and the world’s largest employer of highly skilled professionals. Staff are feeling the strain because over the past decade workforce growth has not kept up with the increasing demands on the NHS.

Digital investment

• A wide-ranging and funded programme to upgrade technology and digitally enabled care across the NHS. These investments enabled many of the wider service changes set out in this Long Term Plan. Over the next ten years they will result in an NHS where digital access to services is widespread.

Funding

• The 3.4% five-year NHS funding settlement will help put the NHS back onto a sustainable financial path. In ensuring the affordability of the phased commitments in this Long Term Plan the current financial pressures across the NHS have been considered, which are a first call on extra funds.

The Health and Care Act 2022

Workforce

An apparent absence of commitment to regular workforce forecasts within the Act will be problematic because of existing NHS staff shortages, and a major challenge is the pressure of an overstretched and exhausted workforce dealing with the rising demand for NHS services after the acute stages of the Covid pandemic.

Changes brought about by the Act

The Act establishes a legislative framework that supports collaboration and partnership- working to integrate services for patients, it includes changes to public health, social care and the oversight of quality and safety.

The Act also includes formalising the merger of NHS England and NHS Improvement, with the resulting body, NHS England, which is responsible for providing national direction for the NHS.

Greater involvement of the private sector in delivering and planning clinical services

In May 2022 the King´s Fund reported that the Act may not have implications for the involvement of the private sector in delivering clinical care in the NHS. By reducing the role of competition and relaxing current procurement rules, it may release the NHS from complex competitive tendering requirements. Independent sector organisations that played a role in delivering healthcare services within the NHS, such as dentistry, optical care and community pharmacy have been providing the private sector for decades, and most GP practices are private partnerships.

The changes to clinical service procurement brought in by the Act may reduce transaction costs and give NHS and public health commissioners greater flexibility over when to use competitive procurement processes.

Will it make a difference to patients?

The emphasis on integrated care means that the Act should lead to improvements in population health and patient experience, particularly for those living with multiple conditions who need support from different services at the same time. Services need to work together more effectively to provide joined-up co-ordinated care that meet individual’s needs in a flexible, person-centred way.

Challenges the health care system currently faces

The Act will not necessarily tackle the immediate pressures facing the health care system. The NHS faces significant challenges including growing waits for care, a workforce crisis and deep health inequalities after decades of funding settlements that failed to keep up with demand for services. Social care is in crisis following years of real-time cuts in funding and the failure of successive governments to reform, these challenges were exacerbated and accelerated by Covid with rising pressures on services.

Going forward

2023 is likely to see more into probing the fundamentals of the NHS such as comparisons to social insurance systems run in some European countries or raising the possibility of charging for seeing a GP. We may also expect to see the political parties beginning to hone down their strategies for health and care as they develop their manifestos for the next general election.

Prime Minister of the UK, Rishi Sunak, said cutting the waiting lists was one of his top five priorities for 2023. He also announced £250m of extra funding to the health service. This is welcome news.

Sir Keir Starmer, Leader of the Opposition, stated that the NHS should always be free at the point of use, but there was also a role for the private sector, including to help clear waiting lists. He also proposed allowing patients to make self-referrals for conditions like back pain to cut bureaucracy.

One of the biggest challenges the NHS faces today is the workforce crisis. We must reinstate the bursary for trainee nurses and let staff know that they are valued.

Waiting times could be reduced if services had a clear focus and the right levels of investment and staffing.

Ambulance delays should decrease. Improving emergency care would enhance ambulance performance times.

The backlog in operations should be sorted out as quickly as possible to prevent more people getting very ill.

Screening services should be increased as part of a prevention strategy for the NHS. Diagnosis should speed up to improve health outcomes. The NHS must work on preventing illness, not just treating it.