John Lister and Paul Evans offer an overview of the NHS’s state of play six months after the general election and the prospects for positive change beginning in this new year.
This week, the Labour government announced yet another enquiry on social care, to an audible groan, and as we publish this article, the Guardian reveals details of further proposals to cut the waiting times for diagnostic tests and report a dubious response from NHS staff.
A week or so before Christmas, Labour’s Health secretary, Wes Streeting, delivered a self-congratulatory Zoom update to Labour activists on what they had achieved in government since winning the election in July.
He declared, “The very worst day in government is better than the best day in opposition,” and told Labour members that ministers should be judged by what they deliver.
But even as he spoke, stressing the level of historic underfunding and inadequate capacity revealed by the Darzi Report and happily blaming the Tories for the dire situation and ‘bumpy ride’ the NHS was facing this winter, new figures emerged to show just how difficult life has become once more for front-line staff in NHS emergency departments.
Slow progress on the fundamentals
As staff battle the ‘quad-demic’ of flu, COVID-19, RSV, and norovirus plaguing hospitals, the lack of sufficient beds still impedes them, as do inadequate community and primary care resources and limited social care.
This means they struggle to discharge patients efficiently after treatment, leading to blocked beds, delays in emergency admissions, congestion in A&E, and long ambulance queues that have been making headlines again.
Worse still, there is little reason to expect this to change much by next winter— as the Labour promise for the NHS has effectively been stripped back to a long-range promise to reduce waiting lists (by March 2029).
Only modest progress has been made so far. The most recent (October) figures show that the total number of procedures patients are waiting for in England is only 230,000, lower than the peak figure of 7.77 million in September 2023. A recent HSJ report has warned that the pace of reduction of the total waiting list fell back in October:
“If the government is to deliver its pledge to restore 18-week waits by 2029, the acceleration needs to resume until the list is shrinking by one million patient pathways per year. But in October the rate of improvement paused at less than 200,000 a year.”
Distracted by savings targets
Part of the reason for this is financial pressures. As The Lowdown has highlighted, ICBs are still struggling to deliver a massive £8 billion in ‘efficiency savings’ for 2024-25. Much of the extra money from the Budget has already been committed, and it will likely make little overall difference.
Our investigation found that NHS leaders identify common reasons for their financial difficulties: the increasing number of mental health patients with more complex issues who require admission, more patients needing ‘special’ care, a rise in serious A&E cases, and higher prescribing costs.
The extra money in Rachel Reeves’ budget has only partially reduced local deficits. Far from building the workforce to meet the needs of the future, our survey of ICSs revealed that workforce restrictions, such as recruitment freezes and cuts in agency and bank staff, are the main response to the centre’s demands for efficiency savings. These restrictions undermine safety, quality of care, and efforts to address waiting lists.
Cash squeeze
Limits on capital spending that have increased the bill for backlog maintenance to almost £14 billion have run alongside continued restrictions on revenue budgets. Just before Christmas, an HSJ report echoed Lowdown analysis, noting that all but three (39 of the 42) Integrated Care systems were falling behind their financial plans for 2024/25, with overspending running way above forecast levels.
Almost half of ICSs (18 out of 42) are now subject to special measures—NHS England’s so-called investigation and intervention programme. This programme involves sending management consultants into systems to rapidly implement efficiency savings and cuts while saddling ICBs with their fees. The list of ICBs in special measures grows longer month by month.
Almost all acute hospital trusts, too, are running substantial deficits. Many are gambling on somehow delivering the lion’s share of their “efficiency savings” in the second half of the financial year, which spans the demanding winter period.
Delays in decision-making
After all his apparent certainty in opposition, Streeting’s approach to the most pivotal issues in the NHS since July has been to kick the can down the road.
Social Care—Today’s announcement of yet another commission on social care has been met with disbelief by those who have seen successive governments duck the issue. The Health Foundation has identified 25 relevant social care commissions, select committee inquiries, and white papers since 1997
Action on social care could ease the pressure on the NHS, which has thousands of beds filled with patients for whom no proper support services are available in the community or social care, especially during the winter.
But despite promising a National Care Service and years of criticising previous governments’ inaction the new government appears just as tongue-tied as its Tory predecessors, as the situation of social care gets even worse.
But this is only the latest in a list of delayed decisions, despite having been elected with a huge majority on a promise to deliver real change.
The planning guidelines for the next financial year, which until 2023 had traditionally been published a few days before Christmas, have been shunted back to some time in the new year, creating more confusion.
The much-promised ‘10 year plan for the NHS, originally to appear in the spring of 2025, has also been delayed to the summer.
Strategic pay talks with NHS unions have also been put back to the second half of 2025. The main unions are calling for direct negotiations bypassing the pay review bodies. A major reform is needed to restore the value of the 20-year-old Agenda for Change pay scales (which began with Band 1 comfortably above the minimum wage but have declined in real value to the point where Band 2 is now just pence above the legal minimum).
Plans to massively increase the number of physicians and anaesthesia associates are causing widespread concern, but here too Streeting has prevaricated. In November, a review under Professor Gillian Leng was eventually set up to seek evidence on the safety of these roles. The General Medical Council, despite its own survey showing that none of its key proposals enjoys more than minority support among doctors or the wider public, took on legal responsibility for registering (and supposedly for ‘regulating’) PAs and AAs in mid-December. The whole issue is now the focus of legal action by angry Anaesthetists and BMA on the one hand (challenging the GMC, whose legal costs are covered by the government) and the self-styled PAs’ “union” on the other.
Less zeal for using the private sector to tackle waiting lists
One positive note has been the much lower profile Streeting has recently given to his mantra in opposition about greater involvement of the private sector as the key to reducing NHS waiting lists.
It’s not entirely clear why this has changed. It could be that this is yet another example of dithering and delay. However, it might also be that, as a minister, Streeting has received a more detailed briefing on the state of the NHS since taking office, which has emphasized how limited the private sector’s assistance would be in addressing the 7.5 million-strong waiting list.
As the Lowdown, NHS Confederation, NHS Providers and others have pointed out the private sector is only geared up to treat the least complex elective cases, so greater use of these services would leave many on the list with more demanding needs waiting even longer for limited NHS capacity to become available.
Another reason could be that the reality of Rachel Reeves’ budget announcement of an extra £22 billion for NHS funding in 2024/25 and 2025/26 has sunk in: analysts are warning that the chronic cash starvation after 14 years of austerity has not yet ended, and as a result, there is no extra money to spend on private providers.
That, in turn, could explain why the private sector has still had no official recognition or reply to its ambitious reported proposal to invest up to £1 billion upfront in expanding its capacity to treat NHS elective patients—in return for guarantees of long-term increased referrals to ensure a return on capital.
The Lowdown has described this plan as effectively an even worse variant of the Private Finance Initiative: instead of the NHS paying inflated costs over 25 years or more for the building of hospitals that it will eventually own, the NHS (and taxpayers’ money) would guarantee a long-term profitable return on the private sector’s investment in itself, leaving no tangible assets in public hands.
If Streeting has responded to this proposal, his reply has not been publicised or shared with Labour members.
More emphasis on primary care
Streeting did unexpectedly bring forward one announcement – £889m increased funding of GP contracts in 2025-26. But any goodwill he may have achieved from this was limited by the failure to resolve the dispute with the BMA over the inadequate GP contract settlement for 2024/25.
That has piled financial pressures on to many GP practices, forcing them to limit or cut the numbers of GPs they can afford to employ in substantive or locum roles and to consider the use of subsidised “Additional Roles” such as Physician Associates instead, while the public still demand appointments with GPs, and GPs are left unemployed.
Nor will Labour’s election promise to “bring back the family doctor” have been helped by Streeting effectively dismissing any prospect of the government reimbursing GPs for the £260m per year additional costs practices face for the hike in employers’ National Insurance payments.
He argued (to their inevitable annoyance) that – unlike trusts and commissioning bodies, which have been protected against the increase – GPs are “not formally part of the NHS”.
This is very different from Streeting’s speech to the Royal College of General Practitioners in October, in which he outlined the vital role of GPs as the ‘front door of the NHS’, and wound up with a call for “every part of the NHS to pull together as one team with one purpose.”
Creeping privatisation
The erosion of the NHS through outsourcing of clinical and support services since July has been slower and more limited than many campaigners feared. However there is so far no indication that the government is willing to actively intervene to implement its promise to turn the tide with the “biggest wave of insourcing in a generation.”
The battle against the outsourcing of support services in Colchester by East Suffolk and North Essex Foundation Trust (ESNEFT) has included a direct appeal by UNISON General Secretary Christina McAnea for ministers to step in and call the Trust to order – but there has been no sign ministers are willing to lift a finger to stop their own policies being flouted by ESNEFT bosses.
In Bath (and NE Somerset), Swindon, and Wiltshire, the Integrated Care Board has awarded HCRG a £1 billion-plus long-term contract for community care services. Twenty20 Capital, a private equity company, makes no secret of its ambition to deliver “significant returns in 2 to 5 years.”
The decision has major implications for over 2000 staff. At the first meeting with HCRG, UNISON was informed that there would be no trade union recognition. The quest for profit when HCRG takes over is also likely to have implications for patients and their care. The ICB has ignored alternatives that would have ensured services remained within the public sector, and there is no indication that ministers are willing to take any action to prevent another blatant breach of their declared policy.
Meanwhile there are worrying signs of another wave of privatisation of non-emergency ambulance (patient transport) services that poor contractors have so scandalously failed in the past. ICBs have been signing contracts of up to 10 years, while one of the first ICB contracts signed has already caused concerns about service failures in Surrey.
The NHS is still a public service
While concerns remain over potential future privatisation, the NHS is still more a publicly-provided service than many believe. The private sector share of NHS spending as shown in Department of Health and Social Care accounts has risen in cash terms to £12.4bn in 2023/24, but has varied as a percentage between 6% and 7% of the total spending for the past six years.
Hospital Episode Statistics paint an even starker contrast between the NHS and private sector. NHS hospitals in England delivered 20.6 million finished Consultant Episodes in 2023/24, compared with just 871,000 NHS treatments in the private sector.
NHS hospitals handled 6.5 million emergency admissions compared with just 110 in the private sector (all but 10 of which were claimed by a small community unit in Beccles, Suffolk).
Moreover, even on day cases, where the private sector, using expertise developed in the NHS, supposedly excels, the NHS itself delivered ten times the 772,000 NHS-funded day cases treated by private hospitals and clinics.
So the private sector is far from taking over, although its share has grown: in 2023 the independent sector delivered 9.63% of all NHS-funded elective care, up from 7.81% in 2019, and the share was still rising into 2024.
However, some types of care have seen much more private sector involvement than others. The percentage of NHS cataract operations delivered by the private for-profit sector increased from 24% in 2018/19 to 55% in 2022/23, and the proportion has continued to grow, with referrals from high street opticians directly to private providers.
CHPI has warned that this outsourcing has a detrimental impact on NHS ophthalmology departments, reducing training opportunities, availability of staff, and income.
Capacity constraints
The main driving force behind the outsourcing of clinical care is limited NHS capacity and its lack of capital to expand its own services.
The extra 5,000 core acute beds that were promised by Rishi Sunak back in January 2023 have not been put in place. When Sunak made the promise there were 100,046 general and acute (G&A) beds open in England. A year later in January 2024 there were just 101,384 G&A beds (1,338 more), of which just 97,799 were ‘core’ beds, the remainder temporary ‘escalation beds’. The most recent winter sitrep figures (for December 15) actually show a decline, to 96,815 core beds plus 2,588 escalation beds.
So front line capacity now is lower than when the extra beds were promised.
As a result, with A&E demand running at record levels, treatment is increasingly taking place in Emergency Department cubicles or with patients lined up on trolleys along hospital corridors.
NHS England has responded to this … by issuing guidelines on how best to deliver “safe and good quality care in temporary escalation spaces” (aka corridors) – advice angrily dismissed by the Royal College of Emergency Medicine (RCEM) as “normalisation of the dangerous” and promoting “corridor care”.
Dr Adrian Boyle, RCEM President said:
“While we understand why this guidance has been issued, as a College we are concerned that it represents a normalisation of what is an unacceptable and dangerous situation. It is not possible to provide truly safe care in environments such as corridors and cupboards.
“So called ‘corridor care’ is a result of overcrowding, which leads to extended A&E stays that we know contribute to avoidable death – a concept the Prime Minister has said should “always be chilling.”
“We and our members cannot, and will not accept, this situation. Rather than advising how to deal with overcrowding, all effort should be focused on preventing it.”
Sadly corridor care is becoming ever more prevalent, with recent news coverage exposing cases including Stoke on Trent and East Kent, while many more trusts like Royal Lancaster Infirmary have been under extreme pressure.
The RCEM has also highlighted statistics for November that show that in England last month, 150,696 patients waited 12 hours or more in major EDs – the second highest for any November on record, and equivalent to more than one in every 10 attendances.
The figures also reveal that November 2024 faced the highest ever November total attendances to major EDs (1,428,050), and that more than one in four patients had to wait more than four hours for a bed after a clinician decided they needed to be admitted
The pressure is also being felt by ambulance services. NHS Providers has warned that in just two weeks over 180,000 emergency patients had arrived by ambulance : “This is over 12,000 more than the same period last winter and nearly 28,000 more than two years ago, highlighting the intensity of the pressures facing the service this year.”
Mental health
NHS Providers also note that mental health services are under mounting pressure: 1.98 million people were in contact with mental health services in October 2024, a similar figure to the previous month, but up by 8.4% compared to a year ago and up by 45% compared to pre-pandemic levels.
Figures show that 804,350 children and young people received at least one contact with NHS-funded mental health services in the 12 months to October 2024, an increase of 7.1% from the previous year and an additional 290,386 contacts since the start of the NHS Long Term Plan.
But services can’t cope: in the three months to October 353,179 children and young people were still waiting for treatment from community mental health services.
Mental health crisis care services are supposed to be delivered via the NHS 111 mental health option. This service was introduced to offer timely and effective telephone and face-to-face support for people experiencing a mental health crisis: the latest data (October 2024) reveals that 165,669 calls to access crisis care through NHS 111 were received, equating to 5,523 calls per day in October, an increase of 14.9% since the previous month.
But only 115,428 (70%) of the calls were answered, leaving over 50,000 calls without a response.
Crumbling buildings
Insufficient capacity in mental health and acute services is worsened by the declining physical condition of many older NHS buildings. The maintenance backlog has more than doubled since 2019, from £6 billion to almost £14 billion (£13.8 billion) at the last count.
43 of the 215 trusts in England now have backlog bills of £100m or more, totalling almost £8.6bn—62% of the total backlog held by just 20% of trusts. While some of these bills might be avoided if planned new hospitals are built, many trusts with large backlogs have no hope of a new build.
Even for trusts that have been included in the various inconclusive plans since Boris Johnson’s empty promise in 2019 to build ‘40 new hospitals’, there is now another agonising delay, with 25 schemes put on hold as the Labour government carries out a ‘review’ of the New Hospitals Programme in the light of Rachel Reeves’ tight-fisted budget. The HSJ reports 16 schemes have been allowed to press ahead – but none yet has any guarantee of the capital they will need to begin building, few have business cases ready to go and fewer still any plans drawn up..
Lack of transparency and accountability
But whether ICBs and trusts report success or failure in delivering their planned savings, there is little, if any, clarity on how they are seeking to cut spending and how far the quantity or quality of services are at risk. There have been isolated revelations of penny-pinching cuts, care rationing, service closures, recruitment freezes, job losses, and petty cuts that will save little but inconvenience patients.
With only vague discussions and unexplained targets, it appears that NHS chiefs are largely (or in some cases exclusively) discussing their planned cutbacks in private sessions, with the press and public excluded. This makes it next to impossible for trade unions to take preventive action or for campaigners to lobby against damaging plans.
Even if it is not possible to persuade Labour to loosen the purse strings and pump in the investment needed to get the NHS back on its feet, campaigners and trade unions have a common cause in pressing for measures to lift the shroud of secrecy – “commercial” or otherwise – from the decision-making processes.
If Labour says there is no alternative to cuts, the public should at least have the opportunity to see what cuts are coming and fight to protect the services and communities at the greatest risk. Trusts and ICBs need to be instructed to make all but the most sensitive decisions affecting individual staff members and properly confidential issues in public session and fully document them.
The Lowdown welcomes information from local campaigners or NHS staff who have evidence on how the spending cuts are impacting services. We wish all readers, activists, and campaigners fighting to defend and improve local services a very happy and successful new year.
Dear Reader,
If you like our content please support our campaigning journalism to protect health care for all.
Our goal is to inform people, hold our politicians to account and help to build change through evidence based ideas.
Everyone should have access to comprehensive healthcare, but our NHS needs support. You can help us to continue to counter bad policy, battle neglect of the NHS and correct dangerous mis-infomation.
Supporters of the NHS are crucial in sustaining our health service and with your help we will be able to engage more people in securing its future.
Please donate to help support our campaigning NHS research and journalism.
Comments are closed.