Winter is coming

The NHS hasn’t collapsed – yet. But it is clearly in serious difficulty. Winter hasn’t even started but already:

  • A & E waiting times in England are at their worst ever
  • The respected health think tank, the Nuffield Trust, is predicting 100,000 people could end up on trolleys waiting for hospital beds
  • Last month hospitals missed key targets for planned operations and cancer treatment

So what has caused this crisis? We believe there are four fundamental issues that need to be addressed.

First, there needs to be an honest discussion about costs and expectations

Politicians, ideally on a cross-party basis, need to have an honest discussion with the electorate about what the NHS can provide, what this will cost and how this will be funded. 

That is important because the UK has:

  • Fewer doctors per head of the population than most other EU countries - 2.8 doctors per 1000 people compared with 4.9 in Spain and 4.8 in Austria.
  • Fewer hospital beds per head of the population – less than 300 per 100,000 people, compared with an EU average of 521.

Second, there needs to be similar discussion about social care.

More older people need care every year but there were cuts of £4.6 billion in social care between 2010 and 2015, only partially offset by some increases in funding from 2016 onwards.  In 2018, the Local Government Association estimated that adult social care services faced a £1.5 billion funding gap by 2019/20, and £3.5 billion gap by 2024/25.

This is exacerbating pressure on the NHS, with bed blocking a national scandal – elderly patients trapped in hospital beds that are needed for other patients because of lack of care available for them outside hospital.

Third, we don’t have a National HEALTH Service.

Despite its name the NHS is actually a national sickness treatment service. Over 95% of its resources are committed to waiting until people fall ill or have an accident and then treating them. Less than 5% is committed to preventing people falling ill in the first place i.e. ensuring national health.

This matters because so much of the illness we see in the UK is preventable and is caused by:

  • Smoking
  • Excessive alcohol consumption
  • Unhealthy diets
  • Lack of exercise
  • Pollution
  • Poor housing
  • Poverty
  • Lack of hope and purpose in life

However, we all know that prevention is better than cure. So if we’re serious about ensuring a sustainable NHS, we need to tackle preventable illness.

Fourth, policy decisions have consequences

It’s surprising that so many politicians seem unable or unwilling to think through the consequences of their decisions. Let’s take a few examples:

  • If you push through a junior doctor contract in the teeth of opposition from junior doctors don’t be surprised if they vote with their feet and leave the NHS. In 2011, before the new junior doctor contract, 71.3% of junior doctors who completed foundation training programmes went straight on to specialty or GP training. Following the imposition of the contract that figure had fallen to just 37.7% by 2018.
  • If you replace bursaries with loans for student nurses and midwives, don’t be surprised if UK citizens stop applying to become nurses, with a shortfall of nearly 70,000 nurses now predicted for a few years time. And don’t expect to top up numbers from the EU. Following the Brexit vote, more EU nurses are now leaving the UK than arriving. 
  • If you introduce changes to pensions that penalise senior doctors for working overtime, don’t be surprised if they stick to their contractual hours and operations have to be cancelled

It isn’t rocket science. If you insist on making policy decisions that deter health professionals from working in the NHS, don’t be surprised when you’re suddenly short of the health professionals you need to keep the NHS functioning.

We can already see another self-inflicted crisis on the horizon. A points-based immigration system designed to attract the brightest and the best to the UK may help attract doctors – but it will exacerbate the social care crisis. Polls have shown that most people in the UK see the need for social care but don’t want to work in the care sector. They see it as being unpleasant, low paid, menial work. So, if not enough people in the UK want to work in social care, and people from outside the UK aren’t allowed to because they are not ‘the brightest and the best’ – yet we have an ageing population and successive governments that have failed to take seriously the recognition that prevention is better than cure (meaning more elderly people in poor health), who IS going to care for people when care is needed? And that, of course, takes us back to bed blocking in the NHS!

Whatever our analysis there are few quick fixes.

  • To ensure we have as many doctors and hospital beds as our European neighbours will take years (and billions of pounds) to achieve, as doctors need years of training.
  • Reversing the cuts in social care is more achievable and would provide some quicker, short term relief. However, with an ageing population, this means that more funding or more imaginative approaches to social care would soon be needed.
  • Tackling preventable illness offers the best long-term solution. It would reduce demand for both medical treatment and social care and help the NHS become financially sustainable again. However, any government would also need to manage a transition period. Before the benefits start to show through there will still be pressure on A & E waiting lists and GP appointments to manage.

However, there is one quick fix any incoming government could adopt, to stop scoring own goals. Set a small, expert Health Scrutiny Panel, to advise on the likely implications of any proposed health and social care policies, in particular whether they are likely to help or hinder the recruitment of health professionals – and then follow their advice.

Some initial recommendations:

  1. As a matter of urgency establish a commission to consider the future of health and social care in the UK, to include how health and social care provision can be made sustainable (given the anticipatable pressures on it) including the important contribution a preventative approach can make; how informed public debate can be encouraged; and how cross party consensus might be achieved
  2. Incentivize organisations to improve the health of employees. This should be a win win for employers – meaning fewer sick days lost, enhanced productivity and improved morale. One simple first step would be to incentivize Investors in People to add a new indicator their accreditation i.e. supporting the physical and mental health of employees.
  3. Increase funding for medical schools and university nursing degree courses, to expand the number of UK health professionals on condition that the medical schools and universities amend their curriculum to include a significant focus on preventative health – to enable ‘health professionals’ to begin to truly focus on health and not simply the treatment of illness.
  4. Set up an independent, expert Health Scrutiny Panel, to advise on the likely implications of any proposed health policies for the NHS, its staff and patients – and then take on board the panel’s advice.

Michael Baber November 2019