In his resignation letter to prime minister Boris Johnson last week, former health secretary Matt Hancock said he was “so proud that Britain has avoided the catastrophe of an overwhelmed NHS” and also claimed that “we [now] stand on the brink of a return to normality”.
The evidence for the first of those claims is patchy – ‘overwhelmed’ is a word used too often by leading voices in the health sector these days not to be taken seriously – and the twin threats of fresh covid variants and the forthcoming (and not uncontroversial) health and care bill mean NHS patients are unlikely to experience normality any time soon.
‘Black alerts’ and ‘major incident’ notices – issued by hospitals when they’re dangerously close to reaching 100 per cent occupancy, and the stuff of dramatic headlines each winter over the past decade – have become a year-round rather than a seasonal phenomenon.
Only last week Barnsley Hospital declared it had reached OPEL 4, the ‘operational pressures escalation level’ that triggers a black alert, following a spike in A&E demand said to be unrelated to covid pressures.
In the same week it became apparent that Derriford Hospital in Plymouth had already been operating under the same alert level for a month, and that Manchester’s Royal Infirmary and the North Middlesex Hospital in London had both issued major incident notices.
And just two days before Hancock stepped down, the Royal College of Emergency Medicine’s (RCEM) vice-president Adrian Boyle warned that current levels of A&E demand were “creating a significant and sustained threat to patient safety”.
Within 24 hours came another warning, this time from the Royal College of Paediatrics and Child Health president Camilla Kingdon, who said that emergency departments were overwhelmed with children being admitted, potentially because the support services parents normally rely on weren’t always available.
The pandemic has undoubtedly played a part in the current crisis in emergency and elective care, and the NHS’ vaccination programme may well ease this crisis, at least in the short term, although new covid variants and a widely expected third wave could blunt this programme’s impact.
A hint of how this might play out came just a few days ago when NHS Providers deputy chief executive Saffron Cordery revealed the number of covid patients in hospital on ventilation beds had increased by more than 40 per cent over the preceding week.
The crisis in emergency and elective care isn’t just a current issue, however. It has been building up for more than a decade, and is the result of government policies based on cuts – which have led to staff shortages, bed shortages and a growing reliance on underfunded community services – and a predisposition for service provision by commercial interests.
Consider the issue of handover delays at A&E, for example. With hospitals facing increased demand from those denied care elsewhere within the NHS during the pandemic, reports emerged earlier this year of ambulance waiting times at hospitals in the South East being almost 40 per cent higher than in 2019, leading to fewer ambulance crews being available to respond to other emergencies.
Yet subsequent research by the Labour Party shows that the number of patients forced to wait with paramedics for at least an hour in ambulances and ward corridors across England leapt by 44 per cent in the 12 months leading up to the pandemic.
Commenting on the situation in April, RCEM vice-president Boyle told the Independent, “We were in a terrible state pre-pandemic… the winter before the pandemic was [already] the worst on record since we started collecting four-hour target performance [statistics]… It wasn’t OK beforehand, and there [now] seems to be a normalising of what is abnormal.”
Staff shortages remain a historic problem for the NHS too, with an estimated 85,000 vacancies remaining in England from before the pandemic, and a further 112,000 unfilled posts in social care. Earlier this month a report from the House of Commons health and social care committee – presented with evidence from the BMA that thousands of overworked doctors are considering leaving the NHS because of staff burnout – concluded that workforce planning in the health service was driven by limitations in funding rather than by demand or by creating the capacity to service that demand.
Similar recruitment issues are also impacting primary care, with GPonline recently reporting that there are now 10 per cent fewer GPs per patient compared to five years ago.
Bed shortages, however, lay at the heart of the NHS’ capacity problems, potentially explained away by the strategic reduction in the number of beds (almost 10,000) available for elective surgery last year to accommodate the needs of covid patients.
But the number of beds was already at an all-time low in the months leading up to the pandemic, with more than 17,000 having been cut from the health service’s stock of almost 145,000 that was available in 2010, when the Tory-dominated coalition government initiated a nine-year funding squeeze.
And a report by the BMA illustrates how, in spring 2019, hospitals’ ‘core bed stock’ was no longer sufficient to deal with the level of year-round demand on the NHS, leading more than 90 per cent of frontline doctors to agree that the health service was already “in a state of year-round crisis”. The report highlighted the use of extra ‘escalation beds’, normally deployed only in winter months, well into the spring that year, when 83 per cent of hospital trusts were still using them.
Meanwhile, a Nuffield Trust study conducted before the pandemic took hold found that long-term under-investment had already placed the UK firmly near the bottom of a 31-country league table for health resources. It came in 29th for its stock of hospital beds – with only 2.5 beds per 1,000 people, compared to 8 per 1,000 in Germany.
In March this year, NHS Providers released similar figures, this time for critical care capacity, showing the UK has 7.3 critical care beds per 100,000 people, compared to Germany’s 33.8 and the US’ 34.3 beds.
These statistics help explain why, earlier this month, there were more than 5m people waiting for hospital treatment in England – the highest figure since 2007 – and why the fact that 50,637 fewer people had waited more than 52 weeks (still leaving a total of 385,490) is not that impressive, given that just 3,097 patients had faced such a long delay a year earlier.
Leaked estimates from the Cabinet Office suggest it would cost up to £40bn to clear the waiting list backlog. The latest initiative from the government to tackle the problem, however, represents a national spend of just £160m to fund ‘accelerator sites’, a paltry sum compared to the £10bn offered to private hospitals last year under a ‘framework contract’ to take on NHS waiting list patients.
The ‘accelerator systems programme’ will distribute these slim pickings across 12 areas and five specialist children’s hospitals, with £11.3m going to the NHS Devon Clinical Commissioning Group to pay for three initiatives specifically aiming to reduce waiting times for certain types of operation.
At the time of writing it’s unclear what we can expect from Hancock’s successor as health secretary, Sajid Javid. But it’s interesting to note that his second statement to the media, on the day of his appointment, omitted the words, “My most immediate priority [will be] to see that we can return to normal as soon and as quickly as possible” which appeared in his first statement.
In the absence of any such normality, maybe we should just follow the reality outlined above by the RCEM’s Adrian Boyle, and simply accept that the abnormal has now been normalised?
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