Once again we find ourselves in the middle of an NHS winter crisis. This winter however feels perhaps that a tipping point has been reached. 90 minute response times for a heart attack. 54,000 waiting over 12 hours in A&E for a decision to admit. Waiting lists for planned treatment at over 7 million. The worst recorded excess death rate by the ONS since 1951.
On the first Saturday of the year, the Government did one of the few things it could which was to call a summit. The NHS Recovery Forum, convening people from across the health and social care system was aimed at showing some element of central grip. Best practice was shared and commitments to improvement given. Perhaps the most useful part of this photo-op was the news that a further £250m of further funding had been squeezed Treasury to support hospital discharge.
Whilst the Government is battling through, the public is losing faith in the system. Recent polling by Savanta for the Liberal Democrats found that 81% expect a long wait for an ambulance in an emergency, 83% predict many hours waiting in A&E, 74% think they are likely be treated in a corridor. Labour is a vast 28 points ahead of the Conservatives on which party is most trusted to run the NHS. At the 2019 election this number was in single figures.
Against the backdrop of these pressures, discussion inevitably turns to NHS ‘reform’. Politicians have been talking about reforming the NHS in one shape or another since its inception. Labour’s Shadow Health Secretary has drunk the reform Kool-Aid and won praise for saying that the current model of care is outdated and that the solution cannot be simply pouring in more money. Former Health Secretary Sajid Javid has talked about the need for the NHS to move to a social insurance model.
But what shape might reform take and how can we make it a success? For if there is one thing the NHS has not been short of it is attempts to reform it. So the question we need to ask is why past efforts have not worked and what is the problem any reform needs to solve?
The failure of the NHS reform cycle is in some ways easily explained. The public loves the NHS. Politicians (well most of them) in turn therefore profess their love for it. There is a crisis, some more money is found; until the next time when the process starts over. Along the way there is clamour for reform and calls that the current system is unsustainable. Of the various reforms attempted, most place a heavy emphasis on changing structures as a means for improvement. But structural changes take a long time and rub up against the inevitable short term political cycle. The architects of the structural changes move on and someone else then starts a whole new process. Time, money and effort is wasted.
Some argue that the various reforms the NHS has tried have not worked because they have not explored the fundamental issue that funding a healthcare system through general taxation free at the point of use is no longer working. These voices – usually from the right of the Conservative party – argue for a European style social insurance system as the solution. The same arguments were made during a series of Opposition day debates led by the Tories in the late 90s. Then the pressures on waiting times culminated in the Labour Government’s Wanless review, the 2000 NHS plan, a rise in national insurance to pay for capacity increases and significant cuts in waiting times. It also led to another resounding Labour majority in 2001 and ten more years of Opposition for the Conservatives.
Public satisfaction with the NHS is falling. But there is no public appetite for a move to a different funding model and any such move to another system would consume time and effort that we simply do not have. It is also unlikely to deliver the benefits envisioned. A number of NHS-style funded systems from Denmark to Sweden to New Zealand to Canada are all able to deliver better health outcomes. A better question to ask is what can we learn from them to improve our system, rather than overhauling it entirely.
Other regularly vocalised problems are that the NHS is overmanaged, that there is too much waste, structures are too complex and that there is too much involvement from the private sector. Such arguments ignore the fact that only 2% of the NHS workforce are managers, compared with 10% in the wider economy and that the NHS is ranked 4th out of 11 on efficiency when put alongside other advanced healthcare systems (indeed it was first back in 2017). New NHS integrated care systems are the latest structural change being tried and the focus on integration and breaking barriers across the system which worked during the pandemic needs to be given time to work. The amount of spending on private healthcare by NHS commissioners has been fairly static at 7% for the last decade.
This does not mean the NHS is being as run as well as it could be. It does though serve to highlight that cutting managers, headlines about reducing waste, changing structures again or blaming privatisation are not shibboleths that will solve the fundamental problem.
Indeed all of the above is at best a distraction. The main problem the NHS faces is capacity. We do not have enough beds.
Analysis by the King’s Fund demonstrates that the total number of NHS hospital beds in England has more than halved over the past 30 years while the number of patients treated has increased significantly. Other similar health systems have also reduced numbers through closing long term beds for older people and in light of medical innovations, such as day surgery, but we have gone further.
We do not have the right equipment.
Figures from the OECD in 2021 find that the UK has fewer scanners than the majority of comparable OECD countries at 8.8 CT scanners per million compared to an OECD average of 25.9 and 7.4 MRI scanners per million compared to an OECD average of 16.9.
The NHS and the life sciences industry was able to undertake a global leading approach for the Covid-19 vaccination programme from research to procurement to delivery. But the fundamentals of a technology enabled health system remain a long way off. Researchers at the Institute of Global Health Innovation (IGHI) at Imperial College London, have found that NHS Trusts were using at least 21 different electronic medical record systems which are unable to effectively share information. 23% of hospitals are still using paper records.
We do not have a high functioning estate.
The NHS has a maintenance backlog bill of £10.2bn. This has increased by 11% in the last year and more than half of the total backlog is classified as a high and significant risk. The maintenance backlog began to rise significantly in 2014/15, as transfers from the capital budget started to plug gaps in the revenue budget grew. The annual NHS capital budget is only 6% of total health spending.
The other side of the capacity challenge is staff.
There are currently nearly 1.24 million full-time equivalent staff working in NHS trusts and commissioning bodies in England. This is 34,000 more people than a year ago, an increase of 3%. Since 2010, there are over 34,170 more doctors and over 44,820 more nurses working in the NHS. However the latest NHS data still shows over 130,000 vacancies, a number that has increased significantly on the same period a year go. The nurse vacancy rate is running at 11.9%, equating to over 47,000 vacancies. This has increased over the last year by 8,000. The Government has also admitted it will not reach its target of increasing the numbers of GPs by 6,000 by the next election.
The big issue on staffing is retention. The reasons for leaving vary including the search for a better work/life balance, poor working conditions, lack of promotional opportunities and pay. For hospital consultants and GPs pensions taxation issues are regularly cited as reasons for leaving or early retirement.
The way to reform the system is through investing in these two distressed areas. With the right sustained investment in capital you will make the system work more effectively and efficiently. Silos will be broken down, information will flow and new technologies scaled more easily. Investing in the retention of the workforce will improve the ongoing management and delivery of services and clear backlogs. Both of these structural pillars will in turn help increase the capacity and functionality of the system to then enable changes to the way services work to take place.
Both parties are starting to take the workforce problem seriously. Jeremy Hunt’s commitment to a long term workforce plan at the Autumn Statement could finally be the change needed. However such a plan is unable to be written without an end to the NHS pay disputes the Government faces and which the Treasury must find a solution to. Labour for their part have committed to an expansion in NHS staff funded through abolishing non-dom tax status. But for both parties any long-term staffing plan will need to not provide more of the same but recruit into roles that can deliver a more modern model of care focused around more home and community-based care.
On capital, the lesson from recent years is that short-term capital to revenue financial switches may help you muddle through financially, but they create a much bigger delivery problem down the line. Analysis from the Institute for Fiscal Studies has shown that the NHS is struggling to increase treatment volumes above 2019 levels for many types of care. GP appointments and first cancer appointments are important exceptions. Ensuring capital funding is ring-fenced and that the new integrated care systems adopt a whole-systems approach to capital bids so that new funding maximises the benefits across primary, secondary and social care should both be part of future capital strategies.
But on its own even this strategic investment-led approach to enabling health reform will not solve the NHS crisis.
This is because we find ourselves not in an NHS crisis, but a healthcare crisis. And it is only by looking at it through this wider lens that we can start to properly address it.
Successive governments have sought to wrap themselves in the NHS flag. Protecting it, whilst cutting services elsewhere in public health and social care. It is the outcome of this false economy that we now find ourselves in.
The pandemic gave us two big and obvious lessons. First, if you have a population in poorer health, they will need more healthcare and overwhelm the health system at times of pressure. Second, if you do not invest and improve social care, given demographic shifts you will find your health system cannot function as beds are full.
On both these agendas, public health and social care, Government action has been and is inadequate. A health inequalities white paper has been abandoned. A smoking review ignored. Obesity policy long grassed. Social care reform delayed again.
If politicians want to reform and improve the NHS, they should start with a clear investment plan in staff and capital. Such a plan would deliver a better functioning estate, improved IT and administration, increased adoption of innovative technologies and practices, reduce inefficiencies and deliver increases in capacity. It will also provide the bedrock for breaking down barriers between services and delivering the types of patient focused reforms politicians crave.
But if the next Government really wants to support the NHS long-term, they are going to need to start investing more fundamentally in both public health and social care. There are no shortcuts to a better NHS, beware of politicians who claim there are.
Richard Sloggett is Programme Director, Future Health Research Centre & former Special Advisor at the Department of Health and Social Care (2018-2019)
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