The list of impossible tasks
The customary pre-Christmas Eve letter to NHS bosses and leaders setting objectives for the next financial year was significantly shorter than usual in 2022, with the list of impossible things to do scaled back from 130 or so to 31 “national objectives”: but even the reduced list will have made grim holiday reading and set up the NHS in many areas for fresh failures well before the new year even started.
The whole document and the list manage to avoid any mention or reference to the ongoing pay dispute, or the inflationary crisis which is the background to it, but which affects NHS trusts as well as the pay packets of staff who have had no real terms pay increase for well over a decade.
With their eyes and ears firmly blinkered and blocked to the real world, NHS England bosses manage to combine setting completely improbable targets with actual retreats. Eagle-eyed HSJ correspondents have identified a series of targets and ambitions that have been dropped altogether this year, including previous priorities on long covid and diversity and inclusion, commitment to support the health and wellbeing of staff, and continued funding of mental health hubs for staff.
From the very first line the one-page summary list of objectives (page 7) marks a retreat from previous stated targets, with a call somehow to reduce A&E waiting times “so that no less than 76% of patients are seen within 4 hours by March 2024” – effectively abandoning any hope of returning to the 95% target, which has not been achieved since 2015.
The most recent figures (December 2022) show an overall average of just 65% of A&E patients treated within 4 hours, but just 49.6% of the more serious Type 1 cases which are more likely to result in emergency admission. This is the worst performance on record.
SIXTEEN trusts fell below 40% of Type 1 cases treated within 4 hours in December. This is a big increase from six in November. (They were: Somerset; Royal Cornwall; Mid Cheshire; Manchester University; Hull; University Hospitals North Midlands; Derby & Burton; Shrewsbury & Telford; Hillingdon Hospital; Chesterfield; East and North Hertfordshire; West Hertfordshire; North West Anglia; Kings College, plus two trusts, Torbay and Devon (29.2%) and Barking Havering and Redbridge (28.6%) dipping below 30%.
54,532 emergency patients were delayed for 12-hours or more in A&E from decision to admit to admission, again the highest number of 12-hour waits on record, up 10,740 from the second highest figure on record, October 2022, and 2,223% higher than December 2019.
As we have pointed out before in The Lowdown, the markedly poorer emergency performance in 2022 comes despite an actual drop of almost 15% in the numbers of attendances in A&E, and a decrease in the proportion of the more serious Type 1 cases from 53% in December 2019 to 47% in 2022.During the whole of 2022 (January-December) the total number of patients attending A&E fell by 18% compared with 2019, while the numbers of Type 1 cases fell by almost 25%.
The problem, after 12 years of inadequate investment in buildings, beds and staff is clearly lack of capacity – in the hospitals themselves and in the social care and community health services that are supposed to be available to facilitate prompt discharge of patients who no longer need a front line acute bed.
So even achieving the new 76% target by March 2024 will be a stretch for most trusts, especially since NHS England makes clear there is no additional real terms funding for the next two years.
Yet somehow NHS England also expects trusts to reduce adult general and acute bed occupancy to 92% or below. This came as figures showed pressure on beds at its highest-ever, with weekly Covid admissions data showing more than 96% of 95,844 adult general and acute beds were occupied on January 4.
NHS England does not plan to reopen any additional beds, but calls on acute trusts, somehow, with no extra funds, to “permanently sustain the equivalent of the 7,000 beds of capacity that was funded through winter 2022/23”.
Community health services are expected somehow to “reduce unnecessary GP appointments,” while the declining number of GPs who have already been delivering a staggering record number of appointments (36 million in October – equivalent to more than half the UK population) are expected to deliver 50 million more appointments by the end of March 2024.
For once NHS England observes a welcome silence on the proportion of GP appointments that should be face to face – an issue right wing politicians and the right wing news media have obsessed about. After even the pro-NHS Daily Mirror managed to invert the figures by claiming “just 73.4% of GP appointments took place face-to-face in October” Pulse editor Jaimie Kaffash has published new research aimed at establishing the facts.
It has revealed the inevitable trade-off between prompt access to an appointment and the proportion of face to face appointments:
“Our investigation showed what many GPs will already know: that to offer face-to-face consultations, practices generally can only provide lengthier waiting times and fewer appointments conducted by GPs. The table below show that those in the bottom decile for face-to-face appointments have the shortest waiting times at just under five days, while those that offer the highest percentage of appointments that are face to face have an average waiting time of just under eight days.”
Pulse analysis of NHS Digital data reveals that:
“almost half of all appointments – 46% – are taking place within a day of the booking. Meanwhile, 69% were seen within a week. Pulse analysis showed that the average wait is a week exactly.
“Nonetheless NHS England is now insisting, again with no additional resources on offer, and even as demoralised GPs leave in disgust: “everyone who needs an appointment with their GP practice gets one within two weeks.”
GPs are also lumbered with the heavy lifting to deliver two of the three tasks for prevention: increasing the proportion of patients with hypertension receiving treatment and implementing new NICE guidance to ensure up to 15 million more potential cardio vascular patients receive statins.
NHS England is calling for local health bosses to “recover dental activity towards pre-pandemic levels”. This has been followed by clashes in the House of Commons over Rishi Sunak’s wildly dishonest statement to MPs claiming that dentist numbers have increased, they have been given a new contract, and that more money has been put into dental services.
This has been condemned by the British Dental Association, whose response spells out the problems that Sunak and NHS England ignore:
“The ongoing exodus from the NHS workforce saw 24,272 dentists perform NHS activity in England during 2021-22, lower than levels seen in 2017/18.
“The BDA does not consider recent tweaks to the discredited NHS system as a ‘new contract’, given formal negotiations on substantive change have yet to begin. These minor changes – which had no new funding attached – are unlikely to increase access or improve workforce retention.
“The budget for dentistry has been subject to a decade of savage real terms cuts, and with inflation at record levels the BDA estimate it would take an extra £1.5b a year simply to restore resources to 2010 levels.
“In August the PM pledged to “restore” NHS dentistry by ringfencing its funding, strengthening prevention and encouraging dentists to stay in the health service. … There is no evidence any element of the plan has been taken forward.”
Indeed far from improving dental services, research undertaken by the BBC over the summer revealed nine out of ten practices in England were unable to take on new adult NHS patients.
Elective waiting times
NHS England moves relentlessly on, demanding an end to referral to treatment waiting times longer than 65 weeks by March 2024, and, according to the HSJ, now giving trusts just 20 days to book in dates for all 48,000 patients currently waiting over 78 weeks.
On cancer care, however, which most people would deem more urgent, the target is much more vague: “Continue to reduce the number of patients waiting over 62 days”. In addition there is a requirement to speed up diagnostic services so that 75% of patients urgently referred by GPs for suspected cancer are diagnosed or given the all-clear within 28 days.
This will inevitably pile more pressure on to overloaded and under-resourced diagnostic services, which again have a remarkably vague target: “Increase the percentage of patients that receive a diagnostic test within six weeks in line with the March 2025 ambition of 95%.”
NHSE makes clear that the aim is a 25% expansion in diagnostic capacity, and some of this at least has been funded, although only for the purchase of equipment and development of new Community Diagnostic Centres – leaving open the question of how staff are to be employed to work the kit and deliver the service:
“£2.3bn of capital funding to 2025 has … been allocated to support diagnostic service transformation, including to implement CDCs, endoscopy, imaging equipment and digital diagnostics.” (p12)
Maternity and mental health
Maternity services is the only area in which there is a specific mention of staffing numbers, with a requirement to fill more vacant posts.
Mental health services, which were given empty promises of increased numbers of staff, face six tough new challenges from NHS England.
The first is to move towards the national ambition for 345,000 additional individuals aged 0-25 accessing “NHS funded services” – clearly recognising that many of these services have been hived off to private contractors
NHS trusts also need to deliver a 5% year on year increase in the number of adults supported by community mental health services, and “work towards eliminating inappropriate adult acute out of area placements”. The specific reference only to adult out of area placements underlines the continued gaps in provision of local mental health care for children and adolescents – where this is also a problem, but kicked into the long grass by NHSE.
On finance, trusts and Integrated Care Boards are required to deliver a “balanced net system” – despite widespread underlying deficits in trusts and ICBs, and the hugely ambitious targets for cash savings and “efficiencies” – many of which are admitted to be non-recurrent, and therefore concealing the scale of the financial challenge in 2023-2024.
The document: key details missing
Over and above the list of tasks, the NHS England guidance is as interesting both for what it leaves out and for what it says.
The document makes clear that “total ICB allocations [including COVID-19 and Elective Recovery Funding (ERF)] are flat in real terms with additional funding available to expand capacity.” (p5)
It makes clear that limited extra capital funding will only be available to those who have least financial problems and best balanced their books: “Capital allocations will be topped-up by £300 million nationally, with this funding prioritised for systems that deliver agreed budgets in 2022/23.”
Given the constraints on NHS funding, it is especially galling for NHS staff to find that the one area that NHS England wants to expand is use of “independent sector providers,” which must be “actively included” in local system plans (p11).
It’s not until page 11, however that NHSE admits that hopes of balancing the books depend once again on “returning to and maintaining low levels of COVID 19” – a desire that has yet to materialise, with thousands of front line beds still occupied by Covid patients.
There are repeated references to documents that either don’t appear at all on the NHS England website or have yet to be written, notably the “Revenue finance and contracting guidance for 2023/24,” for which no publication date is given.
There is a tantalising promise that NHS England working with DHSC and the Department for Levelling Up, Housing and Communities “will develop a UEC (Urgent and Emergency Care) recovery plan with further detail … in the new year,” (again no date). (p8)
The document calls (p9) for “increased referrals into Urgent Community Response (UCR)”, but does not address the enormous geographical variation in levels of provision and performance, with nine of the 42 ICB areas (Derbyshire, Lincolnshire, Leicestershire, Herts & West Essex, Staffordshire, Cornwall, Cambridgeshire & Peterborough, Bristol & North Somerset, and Dorset) registering minimal if any delivery of services in the most recent statistics.
NHS England goes on to promise another major policy document, the “General Practice Access Recovery Plan” – also due “in the new year”. (p10) The 23/24 guidance refers to “the vision outline in the “Fuller Stocktake” – but no such document comes up on a search of NHS England’s website.
It also refers to “the Cancer Alliance planning pack” (p12) which also yields no results on searching the website, although doing so reveals that the “NHS Cancer programme: Quarterly report overviews” began in 2019 but have not been published since 2021, and the page on Cancer Alliances has not been updated since it advertised “Cancer Alliance priorities 2019/20”.
Another promised document is “a single delivery plan for maternity and neonatal services” … some time in 2023 (p13), and help for “ICBs to co-produce a plan by 31 March 2024 to localise and realign mental health and learning disability inpatient services over a three year period as part of a new quality transformation programme.” (p15). So this might yield action by 2027.
Even NHSE seems to have realised that they while they might be able to ignore the pay dispute taking place around them, they can’t completely ignore the question of workforce. So the “to do” list and two brief sections of the pre-Christmas letter make reference to the “NHS People Promise,” arguing that a “systematic focus” on this is the key to staff retention (p3).
For those who haven’t seen the Promise, it makes bizarre reading in today’s context. Obviously it has some perfectly reasonable aspirations and values: but Promise 2 reads:
“We are recognised and rewarded”
“A simple thank you for our day-to-day work, formal recognition for our dedication, and fair salary for our contribution.”
In practice staff are lucky these days to even get the “thank you”: recognition of dedication and fair salary have not been seen for over a decade, and the government is so far standing firm against any attempt to change that.
Promise 3 is headed: “We each have a voice that counts,” and promises:
“We all feel safe and confident to speak up. And we take the time to really listen to understand the hopes and fears that lie behind the words.”
Of course this is not true either: heavy handed central comms staff from NHS England are gagging those senior managers who might otherwise have the guts to speak up about the situation on the ground in particular trusts and services, whistleblowers are no more protected than they were 20 years ago, and staff face the threat of disciplinary action if they speak out publicly on their concerns for the quality and safety of services.
Promise 4 is again at variance with the experience of too many junior doctors, nursing staff on 12-hour and longer shifts: it states
“We are safe and healthy. We look after ourselves and each other. Wellbeing is our business and our priority – and if we are unwell, we are supported to get the help we need. We have what we need to deliver the best possible care – from clean safe spaces to rest in, to the right technology.”
These words just take the breath away. This is the same NHS England that has just decided to pull the funding for mental health hubs brought in to support staff traumatised by the scenes they witnessed and the ways they had to work during the pandemic, even while hospital staff are being further stressed and scarred by the nightmare scenes in A&E departments and corridors, and ambulance staff are forced to watch blue light patients die in the back of ambulances as they queue to hand them over to hospitals.
This is the same NHS England that has seen the total bill for backlog maintenance needed to keep hospitals clean and safe and update clapped out equipment soar above £10bn, and knows around a dozen hospitals built in the 1970s with defective concrete planks are literally falling down, rehearsing emergency plans to evacuate patients if a ceiling collapses.
Nor is the technology right. Only a few weeks earlier the BMJ highlighted how failing IT infrastructure was undermining safe healthcare in the NHS.
NHSE know full well that this promise is not worth the webspace it is published on, and will simply infuriate any NHS staff who see it.
And as staff shortages bring a return to some of the worst excesses of demands on shattered junior doctors, and nurses report crying daily at the conditions they face each time they report to work, it is perhaps even more galling for many to read Promise 6:
“We work flexibly. We do not have to sacrifice our family, our friends or our interests for work. We have predictable and flexible working patterns – and, if we do need to take time off, we are supported to do so.”
This may be true of some senior managers – and good luck to them. But it’s all too clear that few staff at the front line of patient care would recognise this as their reality at work, or have any faith in a promise that it could be the situation.
If this is the best NHS England can offer as a hope to retain more staff, there are far worse problems coming down the line, with staff forced to fight to stop endless real terms pay cuts, an NHS bogged down with “flat funding,” seeking “savings” rather than matching resources to needs, and promising only the most ludicrous fantasies of improvement for the next two years at least.
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