If news stories are to be believed, it can seem as though the NHS is in a constant state of crisis. Indeed, three years ago the head of the British Red Cross caused a stir by describing the NHS as in a state of ‘humanitarian crisis’ such was the concern about people waiting in (or to gain access to) hospital accident and emergency departments.
Evidence from recent analysis of NHS activity data underlines the very real pressures being experienced across the NHS. The picture is one of growing waiting lists for operations, longer waiting times to get a GP appointment, delayed starts to treatment for cancer, and ever more people turning up at A&E departments.
Holding a General Election in mid-December poses a particular risk (or opportunity, depending on the party) for politicians keen to set out their policy intentions for the NHS. Although the NHS is sometimes said to now be in a permanent state of ‘winter pressure’ there is inevitably additional demand for services in winter, as cold weather, flu, norovirus, pneumonia and other factors bear down on vulnerable patients, and indeed health and social care staff.
What then are the main causes of NHS pressure that need attention by a new Government?
First is funding, following a decade of sustained and damaging constraints to the level of annual investment in the NHS. Although more fortunate than other public services in having had effectively flat funding for ten years, followed by recent increases as part of Theresa May’s 70th birthday gift to the NHS, expert analysis has consistently pointed to the damaging effects of not continuing with the 4% annual increases in funding required just to keep pace with rising demand for care and costs of inflationary items such as drugs.
Second is scarcity of workforce, which for many NHS managers and clinical leaders is the most pressing problem. Even where funding is available for new or replacement posts, it often proves impossible to fill vacancies, as the people are just not there. The reasons for this are complex and various and include: a failure of long-term workforce planning (for example, a 40% decrease in the number of community nurses at a time when policy is calling for much more care outside hospital settings); political decisions such as removing the funded training bursaries for nursing, midwifery, physiotherapy and some other professions; a major decline in immigration from EU countries following the Brexit vote; and the pressures within the NHS meaning that it has got harder to retain staff.
Third is a need for properly planned and available capital expenditure, and in particular money needed for tackling significant levels of backlog maintenance, replacing dated medical equipment, and investing in renewing ageing estate, whether community clinics, mental health facilities, or hospitals. Furthermore, there is a pressing need for resource to support much-needed investment in IT, cybersecurity measures, and enabling modern access to services and care. The NHS remains far too reliant on snail mail for sending out appointments and information to patients and families, and the ability to phone or email one’s care provider remains all to elusive for many of us.
Fourth and finally is the vexed issue of social care reform, or rather the complete lack of political to confront the need for a major overhaul of how social care is funded and provided in England. Although not strictly speaking part of the NHS, social care is inextricably bound up with health care, and the sustained and vicious cuts to local authority social care funding in recent years has led to major pressure on other parts of the public sector, and health care in particular. Older people living with dementia not meeting the ever higher threshold for state funding are too often left slipping into household squalor, malnutrition, loneliness and isolation for want of social care support at home. Others are stranded in hospital beds, awaiting a residential or home care place. People living with enduring mental health problems, or with learning disabilities face totally unacceptable waits for care and support, and too often such services are judged as inadequate by regulators, or more importantly the people in need of care, and their families.
So what is it that politicians need to do to address these four fundamental challenges faced by the NHS?
First they need to have a serious plan for long-term sustainable funding of the NHS, setting out honestly what this will mean in terms of increased taxation. The plans to underpin such investment have all been worked up and are ready to be implemented, including the excellent work of the House of Lords Committee on the long-term sustainability of the NHS, and the NHS Long-Term Plan. Interestingly, the manifesto funding pledges for the English NHS made by the three main political parties are ‘relatively similar’ according to expert analysis, We need to know more however about how these increases will be funded (is it new money, or taken from other public services?) and crucially, on what areas of health it will be spent.
Second, they need to work closely with professional bodies and education providers to develop realistic plans for building a long-term workforce for the NHS (and indeed social care), accepting that this will need flexibility about migration policy, investment in training and education, and a readiness to explain to the public why a wider range of health professionals will deliver care, including through the means of technology such as on-line and app-based services. As things stand, the manifestos all acknowledge the workforce crisis in the NHS, and have proposals to address it, albeit they lack detail about exactly how staff will be found in the short to medium term, and what blend of policy actions will be adopted.
Third, rather than arguing about how many new hospitals will be built (or existing ones upgraded) there is a need for a bold long-term plan for overall capital investment that supports vital health priorities, with a strong focus on general practice and community health facilities, a major upgrade of mental health care provision, and modernising hospital buildings with sophisticated IT infrastructure as part of this. Manifesto pledges suggest that Labour (£15bn) and the Liberal Democrats (£10bn) have heeded this critical point, but the Conservatives (£2.7bn) are indeed appearing conservative about the extent to which they acknowledge a need for more NHS capital funding.
Finally, and most importantly, there is need to commit to work in a serious and committed cross-party manner to draft and enact legislation to reform the funding and provision of social care. This is proposed by the Labour Party as a new National Care Service to offer free personal care to over 65s and introduce a cap on overall costs of care. No more commissions or inquiries are needed into this topic (although both the Conservatives and Liberal Democrats seem to propose this) for there has been more than enough analysis and modelling of options. Reforming social care would be one of the greatest Christmas electoral gifts that we could ever receive as a nation, and the one that is needed above all others as a way of enabling a sustainable overall health and care system that will meet current and future needs.
Professor Judith Smith is the Director of the Health Services Management Centre at the University of Birmingham.