Lowdown on the key issues in 2023

Throughout the year the Lowdown has reported on the major policy topics affecting health and care in this country. While NHS staff worked hard to treat over a million people everyday, the rising waiting lists lay bare the reality that the NHS does not have the capacity to keep pace with demand. 

The growing crisis in staffing, hospitals in disrepair, struggles with debt and the inadequate focus on preventing sickness all signal a dangerous lack of progress in building up our NHS in the wake of the pandemic.

Staffing

The NHS staffing crisis was a key issue in 2023 covered by The Lowdown. What should have been a positive event – the publication of the long-awaited long-term workforce plan in June 2023, soured fairly quickly as experts questioned just how it would be implemented. The initial release of the plan contained little detail, but questions were soon raised over the lack of sustained funding, availability of training places for the planned increase in trainees, and changes to medical training.

By November 2023 an in-depth analysis of the plan by the cross-party Public Accounts Committee led to much criticism, in particular the lack of funding estimates and the committee had “serious doubts” on how the plan will be achieved.

Staff shortages will not be helped by new immigration regulations restricting the right of workers – even those coming to work in shortage occupations – to bring family members to live with them in Britain. The new £38,700 minimum wage to qualify for family visas means that the new rules cover almost all the main pay bands of nursing staff.

A key part of the workforce plan, the expansion of medical associate professionals (MAPs) within the NHS, hit the headlines in 2023. The workforce plan is heavily reliant on the expansion of MAPs, primarily physician associates (PAs) and anaesthetic associates. A Lowdown explainer covers just what MAPs are and why their expansion in the NHS has triggered a backlash from doctors, with the BMA and the Royal College of Anaesthetists calling for a pause in recruitment and the GMC asking NHS England to confirm that there is no plan to replace doctors with PAs.

Pay

The workforce plan included some details on retention of staff, but managed to completely ignore the issue of wage rates. Contentious after a long pay squeeze and recent rising prices, the government’s refusal to negotiate lit the spark on industrial unrest. Through 2023 the NHS experienced a wave of strikes over pay involving a broad spectrum of clinical staff, including junior doctors, nurses, consultants, radiographers and ambulance staff. As the year comes to an end, much remains unsettled with a junior doctor strike from 20th – 23rd December and then again in January 2024, the consultants as yet to decide whether to accept a pay offer, and nurses threatening more strikes in 2024. 

Infrastructure

Over 2023 the NHS’s infrastructure continued to fall into disrepair. In December, The Lowdown reported that the most recent official figures show England’s NHS backlog of maintenance has rocketed by 13.6% in the last 12 months to a massive £11.6 billion, more than double the 2016/17 figure of £5.5m: it reflects the chronic lack of capital available to maintain, let alone expand or improve England’s NHS. 

The Lowdown has calculated that £3.9 billion is classed as ‘high risk,’ which is defined as “where repairs/replacement must be addressed with urgent priority in order to prevent catastrophic failure, major disruption to clinical services or deficiencies in safety liable to cause serious injury and/or prosecution.”

And if you were wondering what happened in 2023 to the new hospitals programme, those fabled 40 new hospitals by 2030, well reality hit. By August a report from the National Audit Office confirmed that there is no chance of the pledge being fulfilled. News that surprised nobody much.

In October The Lowdown also covered how high profile promises of an extra 5000 hospital beds and 800 ambulances to avoid the chaos of winter 2022 – made by NHS England and backed by Rishi Sunak at the beginning of 2023, stood very little chance of being delivered within the year.

Funding

The financial situation with the integrated care systems and integrated care boards (ICBs), which have now been statutory bodies for over 12 months, has been worsening throughout 2023.

Research published in September by The Lowdown found that with few exceptions ICBs, and especially acute hospital trusts, are facing huge financial problems, forcing consideration of ever-larger scale “efficiency savings”, outright cuts and “unpalatable measures” as they struggle to stretch inadequate budgets to meet tough targets at the same time as coping with continuing high levels of cost inflation.

The Lowdown reported in November how the situation has been worsened by the government (Treasury) refusal to allocate any additional money to the NHS to cover the extra costs of keeping services going during the repeated rounds of strike action, even though these were triggered and prolonged nationally by the government’s own stubborn refusal to negotiate on NHS pay, especially junior doctors.

NHS England has now estimated these costs as totalling around £1 billion. So in the absence of additional funds, they have had to hold back efforts to reduce the 7.7 million-strong waiting list and further cut back already pared-down plans for digitisation in order to free up £800 million to allocate towards the costs of the strikes.

Privatisation

The private sector continued to play a role in providing NHS care in 2023, in particular in areas such as mental health services and diagnostics. As reported by the Lowdown in August 2023, the government continues to encourage the use of the private sector to bring down waiting lists.  

However, in 2023 The Lowdown reported on the retreat of the US Centene Corporation from the NHS, with Centene selling Circle its private hospital business, which carried out a considerable amount of NHS elective work in August, followed by the sale of Operose its GP business in December. Reportedly, the company realised that it was not going to make enough profit in this country, not from the GP sector nor the private hospital sector, despite large contracts for elective care with the NHS.

Another casualty in 2023 was the GP company Babylon Health. Once the darling of the digital healthcare sector, the company got into major financial difficulties in late 2022 and in 2023 The Lowdown reported on the closure of all its operations in the US and the sale of its UK business, including the NHS GP at Hand business to eMed.

However, despite these failures, the private sector has not washed its hands of the NHS and still sees profit to be made. In 2023, the Lowdown highlighted how the sector is now a major target for private equity investors. These investors have seen the recent moves by the government to reduce waiting lists and have noted the value of investing in a sector that is underpinned by public funding. Private equity has made investments in a range of healthcare including ambulance fleets, diagnostics, home care, and ophthalmology, all of which work in the NHS.

Private equity has a reputation for destroying companies and communities in order to make a fast profit. Within a 5-7 year time frame private equity companies use whatever means they can – mergers, sell-offs, redundancies, cutting corners on staffing and service quality etc. – before selling up. These tactics have already had a highly negative impact on the education and care sector in this country.

Mental health services

Through 2023 (as in previous years) The Lowdown covered reports on the crisis in mental health services. In February, the story was the government’s broken promise to produce a new strategy focused on mental health. Instead of a long-term mental health strategy, ministers lumped mental health in with chronic physical conditions, such as cancer and respiratory disease in its major conditions strategy. A move that was widely criticised by charities.

For World Mental Health day in October, The Lowdown covered the report – A Mentally Healthier Nation – published by the Centre for Mental Health on behalf of over 30 national charities, representing many thousands of people in the UK, which calls for a long-term mental health plan that protects people’s mental health, reduces mental health inequalities, and improves mental health services nationwide.

The report asks for more investment in better and more equitable mental health services for treatment, but also for action to tackle the root causes of much poor mental health – poverty, racial injustice, and issues within the benefits and justice systems. 

More recently, in November,  The Lowdown covered the shocking rise in children and young adults with mental health disorders and the lack of capacity to treat them, leading in some cases to waits of over two years for care from community services.

Public Health

September saw a number of reports on public health-related matters covered by The Lowdown, including the report Securing our Healthy Future: Prevention is better than cure, produced by the Royal College of Paediatrics and Child Health and the Faculty of Public Health, and supported by the 24 members of the Academy of Medical Royal Colleges, which focused on the importance of preventing ill-health in children.

Other reports were Manifesto for a Healthier Nation: Delivering Change from The Association of Directors of Public Health (ADPH) and a 10 year follow-up report to the landmark study Fair Society, Healthy Lives (The Marmot Review) by the Institute of Health Equity and the Health Foundation.

What all these reports have in common is a call for putting public health at the centre of government policy-making. 

NHS@75

2023 marked the 75th anniversary of the NHS, and these milestones are an opportunity to think about its benefits. In periods of crisis though its detractors take the media touting policy ideas – including proposals to introduce charging for A&E and GP appointments and making richer people pay for their healthcare or take out insurance and this year they came from inside the current government.  In response we produced a series of 12 articles looking at the most common policy questions and suggestions, giving the public evidence based insight into the potential impact, including comparisons with healthcare systems in other countries.