Truth is a casualty in every election, but this time more than ever the NHS cannot afford for its situation to be misrepresented. It is in a hole, beleaguered by a decade of harmful health policy and it needs a clear escape plan that the public can support – writes Paul Evans

Recently I heard a hospital medic speak about a colleague’s experience as a junior doctor, on call, at night covering 5 wards, about 100 patients.

A male cancer patient was under treatment and doing well, the consultant had noticed an infection, picked up whilst he was under-going chemotherapy and so a round of antibiotics was urgently prescribed.

The junior doctor saw the instruction but for whatever reason didn’t tick the box for immediate treatment on the computer system.

Normally this would be picked up by the nursing staff, but on this occasion the ward was understaffed and by nurses who don’t normally work on a specialist cancer ward.

This vital few hours delay meant that her patients condition worsened, he was transferred to intensive care but tragically he died a few hours later.

An avoidable death, a mistake by an over worked doctor, but also a failure of system working too close to the edge.


Country-wide problem

We know from multiple reports and surveys that a lack of staff is compromising care right across the NHS. The health watchdog (CQC) has found that 70% of hospital trusts in England are failing to meet national safety standards.

One junior doctor told the Guardian, “The youngest doctors in the hospital are given dangerous levels of responsibility; there is one newly qualified junior doctor to 400 patients on night shifts. The administration is in agreement, but confess there is not enough money to employ extra staff.”

In a survey of NHS staff, which included nurses, doctors and managers 80% said they had raised concerns about unsafe staff levels. More than half said that no action had been taken.

NHS leaders name understaffing as their number one concern.

The health service is short of 100,000 staff – including 70,000 nurses and 7000 GPs, but analysts predict that this will rise to a deficit of 250,000 staff by 2020 if the NHS continues on the same trajectory.

Despite all the evidence and unified calls for action, the NHS still does not have a funding commitment that can boost its capacity, make it safer and push up the standards of care.

The staffing crisis has been fuelled by funding cuts of £2bn in the education and training of staff, since 2006. Overall health experts blame “an incoherent approach to workforce policy at a national level, poor workforce planning, restrictive immigration policies and inadequate funding for training places”.

The Interim NHS People Plan – the new workforce strategy was only published by NHS England in June. Repeatedly delayed, it has finally arrived several years into the crisis. Despite receiving widespread approval for its dissection of the situation, it was not backed by any significant new money to bring about the sizeable uplift in staff training and recruitment that the NHS needs.

NHS leaders are frustrated, calling for a “funded, credible” workforce plan

This month’s State of the NHS report from NHS Providers concludes that “Current performance levels are the worst in a decade and trying to work NHS staff harder and harder is simply not sustainable”

Trade unions have been running long standing campaigns to introduce safe staffing levels and reintroduce the bursary for nursing students. Alongside the TUC, eight health unions are calling for a long-term commitment to properly fund the NHS – in line with the cost evidence presented to the government by the Institute for Fiscal Studies.


Nail the funding lie

Meanwhile ministers, without any shame tell us that the NHS has received “record investment” – presenting inadequate rises to an already insufficient budget as a reason for celebration.

In reality the NHS has suffered the longest and deepest period of underfunding in its history.

A 9-year funding squeeze has restricted the NHS to annual rises of 1.5% against rising costs of nearly 4% (2010-18).

Year by year the funding gap has grown. Trouble with balance sheets has inevitably translated into human suffering – cuts to services, understaffing, rationing, delays, compromised care and sometimes tragic failure.

Theresa May announced an extra £20bn over five years in 2018, which was recognised by economists as enough to keep the lights on (3.3% a year after inflation) but not the investment needed to improve standards (minimum of 4.1% per year).

In recent weeks Boris Johnson, keen to fix the Tories slash and burn reputation has announced that he will spend an extra £1.8bn on upgrades for NHS hospitals, telling the BBC “I want to stress that this is new money”.

Within a few hours an analysis by Sally Gainsbury, a policy analyst at the Nuffield trust, revealed that £1bn of the money was already in hospital accounts, as restricted savings. Mr Johnson was in effect just giving his permission to spend it.

The hyperbole around the building plans ballooned further out of control with Health Secretary Matt Hancock’s Tory Party conference speech.

“Over the next decade we will build, not ten, not twenty, but forty new state of the art hospitals.”

Alas again analysts exposed this exaggeration, but not before it was reported widely across the media.

Over the next 5 years the NHS will spend an extra £3bn on capital projects, but the majority of the new money will go to just six trusts, each with hospital in bad disrepair and whose projects are already in the pipeline.

A further 21 trusts will receive a small amount of seed-funding to “kick-start” their plans for the end of the next decade.

Cash strapped hospitals have built up a huge backlog of repairs estimated at £6bn. The Health Foundation predict that the NHS needs around £3bn every year for the next 5 years to get a grip on the problem.

Some areas of the NHS, like mental health and community services are getting a bigger uplift this year than the budget as a whole – as ministers will no doubt remind us,  but only after several years of neglect and at a cost to other parts of the NHS as the overall size of the cake is just not bigger enough.



Hospitals have built up a £6bn back log of repairs after their capital budgets have repeatedly been cut and the money used to cover running costs.

Key areas like public health are being cut – 25% less per head by 2020/21, when challenges like obesity related disease are costing the NHS over £6bn every year.

Despite recent announcements The NHS is enduring the biggest funding squeeze in its history – Over the decade average annual rises of 2.1% are too low to maintain standards. Economists agree that more than 4.1% a year is needed to improve them.

Social care spending has fallen by 5% in real terms since 2010/11. Even with recent increases, spending was around £1bn less than in 2010/11.


What does the NHS need?

Health economists agree that the government’s funding pledges fall short because of one simple reality. They don’t meet the inevitable and basic costs of the NHS: Growing numbers of older people, more chronic disease, new treatments and price inflation.

These are challenges which governments in many countries must confront. They mean that health budgets must rise by a minimum amount each year, just for standards to be maintained.

The NHS needs about 4% annual in terms just to meet current cost pressures and that’s without raising the levels of care.

Ministers celebrated “the record investment” of an extra £20.5bn over five years and of course the NHS was relieved, but look at what it means year by year and the new level is still below the average annual increase that the NHS has received since it began, which is 3.7% (1948-2018).

The new NHS 10-year plan contains an ambitious wish list of improved care, which simply cannot be achieved without a realistic and long-term funding commitment which must be based upon the evidence about the costs the NHS faces.


“The NHS faces a triple whammy of rapidly rising demand – 9 per cent over the last three years alone – against over 100,000 vacancies across the NHS and the need to recover from the longest and deepest funding squeeze in NHS history.” – NHS Providers


Social Care and beyond

Of course, the pressures on the NHS are also linked strongly to the fate of other care services. Cuts to adult social care have reduced the number of people receiving these services by quarter. Health conditions are missed and left to worsen until finally people seek help from the ambulance services, GPs and their local A&E.

Emergency departments are often the place of last resort. Increasingly visible are the casualties of austerity; people who have become patients because of neglect, cuts to services and because they have no-where else to go.

Listening to an A&E doctor speak at a public meeting recently, she described her most recent shift – a string of patients with complex needs:

An Elderly lady came in whose leg ulcers had become infected, because of neglect, she wasn’t being cleaned properly.

She treated a young man with a deep wide cut on his face and he wouldn’t say how he got it.

Two young women came in, one was a teenager and she had tried to commit suicide.

The other was an alcoholic and was getting withdrawal symptoms.

Two more of her patients were homeless.

The doctor pointed out that they all had access to healthcare but problems elsewhere in our society and in our care systems had led them to the NHS. The audience applauded loudly as she pointed out that we must do far more to address the causes of ill health – poverty, housing, family break up and addiction.

Policy questions

Almost 40 years ago the Black report concluded that health inequalities were due to many other social problems and recommended a wide strategy of social policy measures to combat the situation. The report was rejected by the Secretary of State at the time and for decades ministers have been failing to confront the reality that these issues are connected and therefore so must be our response.

So how does pressure on the NHS and its evident lack of capacity relate to the wider plans around the NHS? They are inextricably linked and we will be returning to this in Lowdown, as we do battle with our political leaders for an honest debate about what’s happening in our NHS and what it needs to secure its future.



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director of the NHS Support Federation

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