The challenges facing the NHS during COVID and beyond

The British public holds the NHS in high regard, but leaders must address a number of major challenges if it is to meet the country’s growing medical needs

When the NHS roared into life on July 5, 1948, it marked an historic moment both for the UK and the world. It was the first time anywhere that free healthcare was available at the point of use and paid for by the tax system. At the time, health minister Aneurin Bevan said it was “the biggest single experiment in social service that the world has ever seen”. 

The experiment paid off. The health service has been a major source of national pride ever since; surveys show that we love the NHS even more than the Royal Family. But more than 70 years on, the nation looks very different. 

The NHS grapples with considerable challenges such as long waiting lists, staff shortages and a population that is getting older and sicker with increasing rates of chronic diseases such as type-2 diabetes and dementia. These problems existed long before coronavirus, but they have been brutally exposed during the pandemic. Tough conversations about how to secure the health service’s future are long overdue.

Hospital backlog

Once the pandemic is finally extinguished, a major stumbling block will be the backlog of care the crisis has created. In March 2020, the economy and life as we knew it was forced to shut down to prevent the very real risk of the NHS being overwhelmed. Although the worst-case scenario did not occur, many patients dealing with non-COVID needs found the health service was not available for them. 

Routine care and many scheduled operations were suspended to free up resources, so hundreds of thousands of patients could be admitted to COVID wards. NHS England says more than 300,000 people in England have now waited more than a year for routine hospital treatment, the highest number since January 2008. 

Sally Warren, director of policy at The King’s Fund, says long waiting times are likely to be a feature of the NHS for many years to come. “The NHS was already struggling with meeting some of their waiting-time targets coming into COVID,” she says. “They then had 12 months of needing to shift their activity away from normal and now they have new demand as well. The big question is how they can start to recover.”

Morale on the frontline

Bouncing back will be tough without a ready workforce. COVID has put healthcare workers under significant strain. “Doctors are exhausted and in many cases nearing burnout,” says Dr Helena McKeown, workforce lead at doctors’ trade union the British Medical Association (BMA). No one could deny medical professionals across the UK have demonstrated extraordinary levels of commitment during the pandemic, but this has often been to their personal detriment and without adequate protection, she points out. 

There may well be long-term effects for healthcare workers too. Research suggests some doctors and nurses could develop severe mental health problems, such as post-traumatic stress disorder, after battling coronavirus on the frontline.

At the same time, there are simply not enough healthcare professionals in the NHS to meet demand. One in ten nursing posts are currently unfilled, amounting to almost 40,000 vacancies. The UK also has fewer doctors for its population than the majority of European countries, at 2.8 per 1,000 people compared to the European Union average of 3.4.

Anita Charlesworth, director of research at the Health Foundation, believes one reason for the shortage is the government’s reluctance to invest in medical training. It is expensive to train a doctor or nurse and those costs are very visible in a publicly funded system, she points out. But reducing training costs was shown to be a false economy during the pandemic. England’s temporary Nightingale hospitals were assembled in record time, but staffing them was a problem. For much of the crisis, these field hospitals remained empty. 

“Not protecting the NHS became the Treasury’s problem because then we had to shut down our economy,” adds Charlesworth, suggesting that staff should be seen as an asset rather than a cost to the public balance sheet.

Brexit is another sticking point, says McKeown. Freedom of movement enabled the UK to harness the best talent from within the EU. “Now we have left the bloc, the UK is putting up barriers to international recruitment at a time when the NHS needs it most, as well as sending entirely the wrong message to our overseas colleagues about making Britain a welcoming country to pursue their careers,” she says.

Health consequences of public service cuts

A nation’s health isn’t solely determined by the numbers of doctors and nurses, though. The NHS does not operate in a vacuum, says Lindsay Forbes, professor of public health at the University of Kent. Coping with demand for health services is not only to do with the size of the NHS, but is also about factors that cause people to get sick in the first place. “The key thing over the past few years that has caused the NHS to nearly fall over has been the relentless picking away at local government spending,” she says. 

In particular, local authority public health services, which largely focus on preventing disease, reducing health inequalities and improving residents’ health have been reduced substantially, according to King’s Fund research. 

While spending on public mental health services and promoting physical activity has increased, cash for smoking cessation services, substance abuse clinics and occupational health has been largely cut. Many local authorities warn they will have to slice their budgets even smaller in the wake of the pandemic if support from central government is not increased. 

Scrimping on local services will cost the NHS dearly in the long term, says Devon-based GP Dr Michael Dixon, who is chair of the College of Medicine. It will increase demand for downstream acute services such as hospital care. “The fundamental challenge is how we increase the ability of people to stay healthy and look after themselves as much as they can,” he says.

Interacting with the private sector 

Whether some of the NHS’s challenges could be relieved by the private sector is a hotly debated topic. But it’s perhaps a less controversial issue than the public imagines, says Warren. Private companies have always played a role in the NHS; most GP practices are independent businesses, for instance.

Despite claims to the contrary, King’s Fund research shows NHS spending on external providers has not substantially increased in recent years. Warren believes support from private hospitals could be useful in meeting the post-COVID backlog challenge and help the NHS work through waiting lists more quickly.

Calling on private companies doesn’t always bring the intended results, though. The pandemic has exposed the best and worst of this approach. On one hand, the relationship between the life-sciences industry and the NHS has resulted in the development of an effective COVID-19 vaccine and a successful rollout campaign. On a negative note, NHS Test and Trace, the UK’s system for identifying people who have been in close contact with a COVID sufferer, has been widely criticised. 

In March, the Public Accounts Committee warned the impact of Test and Trace, which relies on outsourcing firms such as Serco for contact tracing, is still unclear despite the UK government setting aside £37 billion for it over two years. 

“The NHS is the jewel in the crown,” says Forbes. “We can tinker around the edges with the private sector, but we need to remember the service is the envy of many countries in the world. Just increasing the role of the private sector won’t do anything to reduce the demand on the health service.”

What will save the NHS?

There is no magic bullet that can solve all the health service’s problems, but there are several approaches leaders could explore to alleviate them. First up, the wellbeing of healthcare professionals needs to be an absolute priority following the pandemic, says McKeown at the BMA. “The impact on their mental and emotional health cannot be underestimated. Meanwhile many will have had COVID-19 and will still be suffering the long-term consequences.” 

She would like to see full occupational and mental health services offered to staff, as well as supported phased returns for those who have had to take sick leave. A silver lining to the pandemic is that the public has never been more aware of the amazing work healthcare staff do. And there is renewed interest in wanting to work for the NHS. Applications to nurses courses in England rose by 17 per cent last year compared to 2019, with 28,920 students starting a nursing degree in autumn 2020. 

If the government wants to protect the NHS, it must stop neglecting its poorer cousin, social care, says Warren at The King’s Fund. The pandemic has shone a light on the difficulties many older people face; a large proportion of COVID deaths have occurred in care homes, for instance. But unlike healthcare, elderly care is rarely free of charge and most people have to pay at least some of the eye-watering fees themselves. 

In 2019, think tank the Institute for Public Policy Research claimed giving free social care to the over-65s could save the NHS £4.5 billion every year by allowing more elderly people to get help in the community instead of ending up in hospital. For years, leaders have promised reforms to the social care system, but no concrete plans have emerged. 

This could be set to finally change. In February, a Department of Health and Social Care white paper stated that a roadmap for social care would be announced later in the year. As well as new social care funding models, Warren would like to see more ways of delivering support for older people. A care home doesn’t have to be the only option for those who can no longer live independently. Building more extra-care housing, accommodation that includes personal care such as help with washing, getting dressed and preparing meals, is one possible solution, she suggests. 

The old adage that prevention is better than cure has never been more relevant. Leaders need to focus on improving the health of the nation, says the College of Medicine’s Dixon, and even injecting the NHS with unlimited cash won’t achieve that. Improving housing, working conditions and giving patients more agency in their wellbeing could mean they won’t need a hospital bed in the future. 

Social prescribing, where GPs connect patients to non-clinical community services such as gardening groups or financial advice sessions, could also have a big impact. And Dixon thinks building on the community spirit that was so evident in the UK during the first wave of the pandemic will lead to healthier, more resilient communities. “The nation is going to have to roll up its sleeves,” he says. “Ask not what the NHS can do for you, but what you can do for the NHS.”

Why retention is as much a worry as recruitment in the NHS

Ensuring staff stay in the healthcare service is just as important as hiring them. Failure to boost morale will lead to a mass exodus of talented medical professionals from the NHS, warns Dr Michael Dixon, chair of the College of Medicine.

He says the NHS “has not been a good employer” in recent years. “When I was a young doctor, we were given breakfast after on-call nights, I had a room I could sleep in if I needed to and I could park my car at the hospital,” he says. “But young doctors can’t do any of those things. They’ve not been respected as people who have made a personal sacrifice and that’s created a problem.”

Pay has been another thorny issue for healthcare workers. In March, the Department of Health and Social Care recommended a 1 per cent pay rise for nurses, a figure unions have blasted as “insulting”. The Royal College of Nursing warns large numbers could leave the nursing profession this year as a result.