Following a disastrous pandemic that has drastically cut back the capacity of NHS acute hospitals and piled added pressures and problems on to primary care, community health and mental health services, the government’s 2021-22 mandate to NHS England and NHS Improvement begins and barely goes beyond the level of fantasy and denial.
The fantasy is that the NHS and its exhausted staff can almost instantly recover from the blows they have suffered over the past 15 months: the denial is ignoring the fact that Rishi Sunak’s recent budget, and the miserly additional £6.6 billion funding to cope with the extra costs of Covid fall far short of the allocations needed to get the NHS back on its feet, pay staff a decent increase to convince them they are being treated with respect, and stop some of the more dilapidated hospital buildings literally falling down.
The Mandate begins with reference to the 2019 Long Term Plan, with its combination of 5-year and 10-year objectives, and then supplemented by the Johnson government’s 2019 election manifesto.
Parts of the Plan have been significantly set back by the Covid pandemic, not least the pledges on cancer treatment:
“by 2028 the Plan commits to dramatically improving cancer survival, partly by increasing the proportion of cancers diagnosed early, from a half to three quarters” (p8, p44)
“We will … lower the threshold for referral by GPs, accelerate access to diagnosis and treatment and maximise the number of cancers that we identify through screening.” (p57)
In 2021 the actual picture is very different. There has been a catastrophic drop in numbers of cancer patients referred for hospital treatment during the pandemic, with numbers referred between March 2020 and January 2021 down by 350,000 on the previous year’s figures, according to the latest NHS England data.
The reduction is equivalent to nearly one in six, from 2.2 million to just 1.85 million urgent referrals, and appears to result from patients’ fears leading them to put off seeing GPs to check out early symptoms for fear of Covid-19.
The fresh wave of Covid infection from January of this year will have deterred even more patients. IPPR figures quoted by The Times show a reduction from 44 to 41% in the proportion of cancers caught early enough to be highly curable, and IRRP research fellow Chris Thomas tells the Times:
There has also been a 25% drop in urgent referrals for urological cancer 23% fewer for brain cancer patients and 21% fewer child cancer patients referred.
To reverse this, and catch up on the backlog while also treating the flow of new patients coming in to the system is a major challenge that will require the full resources of the NHS.
But the other major problem is the severely reduced capacity of the NHS as a result of the Covid pandemic. The most recent figures for general and acute beds in the final three months of 2020 show just 79,520 beds were occupied (81%) down almost 14,000 from the same period in 2019, when over 89% of beds were occupied.
With numbers of Covid in-patients reduced to just 3.4% of beds at the end of March, the challenge or reorganising and reopening some of the closed capacity poses questions over numbers and fitness of exhausted staff and the state of run-down hospital buildings.
Bearing this in mind the combined agenda set out in the new Mandate is daunting to say the least:
“The commitments are listed below …:
- “There will be 50,000 more nurses working in the NHS” [but while numbers have increased by 11,000 (3.3%) in the 12 months to January, this includes 8,000 recruited from overseas and nurses who had come back on a temporary basis who had retired or left the NHS. Of the 344,000 nurses and midwives (308,000 whole time equivalents) up to 50,000 are off sick with covid-related illness and mental health problems or shielding for vulnerable family members, and surveys show large numbers of burned-out staff planning to leave, and recruitment of qualified staff from the EU has reduced to a trickle).
- “There will be 50 million more appointments in general practice a year”; [Numbers of appointments have almost recovered from the severe dip during the pandemic lockdown, but numbers of face to face appointments have been significantly reduced – with warnings of the implications of this for reduced early detection of cancer and other serious illness]
- “We will build 40 new hospitals” [The Lowdown has repeatedly exposed the deception involved in this promise, and the growing problems of the six hospital projects prioritised and funded];
- NHS performance will improve over time, once impacts of the pandemic are factored in – bringing down operating waiting times and improving A&E performance; [See above on the actual picture]
- The NHS will continue to contribute towards levelling-up, through its work to tackle health inequalities; [The government is facing a legal challenge over the allocations of money from the £4.8bn “Levelling Up Fund” after it was revealed that 47 of the 56 constituencies awarded cash had Tory MPs. including the prosperous seats of Rishi Sunak and Robert Jenrick. Only 19 of the 40 classed as most deprived were given anything, while five of the 12 towns in the least deprived low priority group – all of them with Tory MPs – also gained funding. Government spending that should be assisting work to level up public health is also being cut in 31 areas and frozen in 69, while the overall allocation across England goes up by a pitiful £45m (0.67%) in 2021-22. The latest cuts come after a £700m real terms reduction in public health funding between 2014/15 and 2020/21 – a fall of almost a quarter (23.5 per cent) per person.]
- The NHS will continue to improve access to primary and community care; [impossible without any real terms increase in funding].
- The NHS will continue to treat mental health with the same urgency as physical health; [A Nuffield Trust report in November warned that: “Mental health services have been underfunded for many years and were under considerable strainbefore the pandemic. The recent Spending Reviewannounced a welcome £500 million of funding for mental health to address waiting times, expand support to reach more people, and invest in the workforce. However, estimates suggest that the costs associated with the predicted increase in demand could be as much as an extra £1 billion per year.]
- The NHS will better embrace technology to improve patient experience; [Still there has been no serious attempt by NHS England to address the problems of digital exclusion that limit the possibility of millions of people, many of them deprived or vulnerable, satisfactorily accessing a “digital first” NHS]
- The NHS will invest in prevention to improve health outcomes; [there is no extra money to invest, and public health spending is being cut in some of the most hard-pressed areas: see above]
- The NHS will continue to improve outcomes for major diseases and long-term conditions; [limited by lack of staff, beds and resources – as discussed above].
- The NHS will accelerate action on reducing stillbirth, maternal mortality, neonatal mortality and serious brain injury; [only now is the government beginning to take action on scandalously poor quality care going back many years in a number of trusts].
- The NHS will continue to support its workforce; [The contemptuous proposal of a 1% pay increase for NHS staff shows how little ministers value the effort and dedication of the staff who battled through the pandemic to save lives – at the risk of their own health. Empty words here will not compensate for genuine steps to make up all the ground that has been lost in living standards since 2010).
- The NHS will manage its finances to ensure overall financial balance in each and every year [coupled with Rishi Sunak’s latest budget with no extra revenue or capital for the NHS this is a formula for cash-driven cuts in services and for growing lists of treatments excluded from the NHS in local areas, forcing patients to go private or go without].
While ministers delude themselves and the terminally gullible with the nonsense of the mandate, hundreds of thousands more patients are waiting in pain for less urgent elective treatment: the number of people who have been waiting for over a year has soared to 304,044 from 1,613 before the pandemic struck.
Former NHS chief executive Sir David Nicholson told the Guardian that “The backlog is truly frightening. We can very easily get to the next election with people waiting over two years.” the NHS Confederation believes could be as much as 6.9m cases by the end of the year as people on the “hidden waiting list” – who have put off seeking help after discovering symptoms of illness – finally visit a GP.
The Health Foundation has since published new figures showing a drop of 4.5 million elective operations carried out by the NHS last year, and warns that “The waiting list is already at the highest level it’s been since comparable records began in 2007, and if it did rise from 4.6 million now to 9.7 million by March 2024 as we estimate, that’s more than double the waiting list now,”
The further £6.6bn funding for the NHS to deal with Covid from the 6 months starting April 1, with a further £341 million for adult social care is nowhere near enough.
It’s £1.4bn less than the £8bn extra costs attributed to Covid over the same period last year, for which just £7bn funding was allocated, on the assumption that the NHS would “save” £1bn by drastically (and disastrously for some patients) cutting back its elective activity, reducing its spending on surgical consumables.
But that saving could only at best be a temporary one, a delay rather than an avoidance of spending. This year amid a chorus of warnings over the scale and impact of longer waiting times and hugely increased waiting lists hospitals are seeking to speed up waiting list treatment and reduce the numbers of long waits, so the extra £1 billion is needed – and more.
The more NHS trusts are able to return to normal and above normal levels of elective work, the higher combined cost of routine and additional ongoing covid workload. The covid toll of physical and mental ill-health among staff is also increasing costs by requiring greater use of agency staff to fill sickness absence.
Rishi Sunak is so far breaking his promise to give the NHS “whatever it needs”. The Institute for Public Policy Research has argued an extra £12bn a year investment is needed in the NHS and care system to try and recover after the pandemic.
It’s clear the austerity regime that has effectively frozen real terms NHS funding since 2010 is still very much alive and kicking.
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