Paul Evans –

The NHS can’t be allowed to return to perpetual crisis, we must convert public gratitude into political pressure to solve the long standing problems in health and social care.


Why do we need to rethink?

Before the virus, the NHS was in its familiar state of high pressure, heading for winter after publishing its worst ever performance figures; missing targets for A&E care, operations and cancer treatment.


Perpetually it works too close to the edge and often over it. At Christmas doctors in a Norfolk hospital were told to make the “least unsafe decisions” in managing patients. Little did they know what was to come, but staff across the NHS were already accustomed to seeing care compromised by the pressure.


Recent studies show that over 3 a three year period 5,500 patients died because they spent too long waiting on trolleys, another identified 1100 deaths from bowel disease because of staff shortages.


Despite both the publication of the NHS 10 year plan in January 2019 and an election campaign brimming with dubious pledges there is still no credible strategy for increasing the capacity of the NHS and social care to levels that meet the needs of our society.


It took Covdi-19 to get ministers to focus on capacity, and yet the speedy opening of the Nightingale hospitals – which have gone largely unused and the restriction of many other non-covid NHS services, proves that we must have a system capable of proper long term planning.


The use of the private sector as the preferred suppliers for testing, pathology and contact tracing during the Covid crisis, even when NHS and public sector facilities are available, is a further worrying indication that policy makers are not fully on board with building-up NHS capacity.


A post-Covid surge in patient demand is widely predicted. Thousands of people are waiting at home for treatments that were postponed by the virus. Cancer Research tells us that over 2000 cancers a week are currently going undetected, many mental health patients are struggling on their own. GP appointments have dropped by 30%, but with a huge wave of patients expected.


The capacity issue is pressing, but it’s not new. The gap between the demand for healthcare and the amount of staff, beds and equipment needed to supply it, has been growing for a decade.


The NHS has cut its beds stocks by 11% (144,555 down 128,326), over the last 10 years – although they have risen slightly in the last year, Over the sametime hospital activity has risen by around 22%. The number of people on waiting lists has risen by 44% in just the last five years.

Planners don’t appear to have got the message. The six new hospitals that have been given the go-ahead under Boris Johnson’s premiership are already faced with the prospect of bed shortages and inadequate capacity – before a brick has been laid.


Across the country bed occupancy is running at 90% on average and often higher in the busiest hospitals. The maximum safe limit is widely judged to be 85%. So why don’t we plan around achieving it? 


Matt Hancock has promised to revise the current strategy so that it  “takes account of the NHS’s capacity to achieve our wider goals in light of developments with Covid-19, once the virus has been effectively managed.”


This should mean an overhaul of the NHS Long Term Plan to decide what can realistically be achieved at the current capacity and to set a genuine path for NHS expansion.


So far core elements of the 10 year plan are being pushed forward before the workforce strategy or the money to support it have been finalised – akin to pushing a car off the production line without an engine.


An example is NHS England’s big idea to transfer healthcare out of hospitals – where it is relatively expensive, and to treat more patients in the community, managed through the formation of new Primary Care Networks. 


Nothing wrong with closer teamworking between GPs, pharmacists and community staff, or in siting care closer to home if properly organised, but the plan has so far meant loading already overworked GPs and community staff with extra responsibilities. Without the extra capacity this pivotal scheme is seen by half of GPs as “unmanageable”


One family doctor told GP online:

‘Sadly it appears to me that there is an expectation that GPs are going to sort out the problems for the NHS through primary care networks; how will this work? Primary care needs a political solution to solve the problems around recruitment and demand.’


The Long Term Plan has aspirations that few would disagree with; about the need to improve detection rates, make services more equitable and to speed up treatment, but these goals can’t be achieved without genuine plans to raise capacity and there are serious flaws in the framework that the plan is built upon.


The last NHS reorganisation – laid out in the Health and Social Care Act 2012, was gargantuan, but failed. Its structure is still legally in place, leaving fragmented players still half acting out the old competition script of buyers and sellers. Quietly though, the NHS has undergone another shakeup. CCGs have merged into much larger Integrated Care Partnerships. Despite promises, no new legislation is yet in place and so the end point, governance and accountability of these bodies is unclear. 


Meanwhile important local decisions, changing local services are being made more remotely from the public. The new goal is integration, but huge questions remain: is there joint funding and organisation for health and social care? Who will take the lead planning role? How will they be accountable? What’s the role of commercial companies and how will that be regulated? So far we are left guessing.


Until the Health and Social Care Act the public had one comforting certainty that the Health Secretary had a duty to provide healthcare. With that removed – by Cameron’s government, It is now hard to see who is ultimately responsible for ensuring that we all receive the care that we need, which leaves us all more vulnerable. 


Replacing it is a rash of public reassurances and fantastic claims: “40 new hospitals”, “50,000 new nurses”, “record funding for the NHS”, but there is still no effective strategy to make sure the arms of the NHS can still reach all those that need it.


Analysing the government’s funding commitment chief economist for the Health Foundation Anita charlesworth said:


“Even with the government’s proposed investment, the health service will struggle to maintain current levels of patient care in the face of growing demand, let alone deliver the ambitious improvements to services promised by the NHS Long Term Plan.”


Staring straight down the camera ministers promise us that “the NHS will get all that it needs”, but so far they haven’t delivered – health economists agree that the 3.1% rise a year across this Parliament is significantly under what is needed.


In fact the proportion of our GDP that we spend on health is falling – which starkly reminds us that the government is doing far less than could be afforded.


The government has created a £14bn Covid fund for all public services, but that is emergency cash not the long term investment plan that is needed.


Ten years of rising demand, starved of adequate resources has led to crisis management and  a £6bn backlog in hospital and GP repairs and building work. 


There are signs too within the NHS Plan of a continued sell off of NHS estate which begs the question how will the new infrastructure and community facilities that we need be built? More leasing from the private sector?


Disgracefully too, we are no nearer a solution for social care, The Conservatives have promised £1bn per year over the course of the parliament to shore up social care, but again economists put this in perspective.


“…this won’t come close to the £4.1bn needed by 2023/24 to address the costs of rising demand and match NHS pay increases. In the meantime, more people will go without the care they need.”


Almost 5000 former NHS employees came out of retirement to stand on the frontline to fight Covid-19, but even their valiant support isn’t enough. The NHS is short of 100,000 staff and in social care the gap is 122,000. 


The challenge to raise capacity so that services are safe and effective is huge and on the other side of this terrible virus we need a plan, a much better plan to achieve it.



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Paul Evans

director of the NHS Support Federation

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