Why the NHS needs more than a funding boost to save it
The NHS got more money in the Autumn Budget, but will remain in a critical condition without a viable workforce plan
Can the NHS survive the pandemic? The question would have been unthinkable a few months ago. But with challenges ranging from daunting waiting lists to growing abuse of healthcare officials, the outlook is foreboding.
These are momentous times for an organisation that has been responsible for the nation’s health for more than 70 years. There’s a huge backlog of care, with almost 6 million people waiting for treatment. The waiting list is rising by about 100,000 a month as more people who did not seek or could not access NHS treatment over the past 18 months visit a GP and are referred to hospital.
The number of patients waiting more than two years has risen to nearly 10,000. People who are seriously ill are unable to access the care and support they need, which puts their lives at risk. In many hospitals, ambulances are unable to unload patients because there’s nowhere for them to go.
The weekly clapping for the NHS feels like a lifetime ago. Today, at the frontline of care, GPs have become the target of public anger and frustration over the challenges faced by the health service. Increasingly, healthcare professionals in hospitals and health centres face abuse from patients and their families.
Dr Katherine Henderson is a senior A&E consultant in London and president of the Royal College of Emergency Medicine, which represents A&E doctors. “It is a sad reality that in recent months there has been a rise in abuse directed towards healthcare workers, but this abuse is not something new to frontline staff or emergency departments,” she says. “It was bad before the pandemic, but there’s a changed atmosphere now.”
For all the talk of a “post-pandemic” world, the NHS is still struggling with a live coronavirus crisis. There are almost 9,000 people in hospital being treated for Covid-19. This takes up resources and requires isolation on wards, limiting admissions of other patients. There are fears this is likely to increase in the winter in the absence of measures like social distancing, compulsory face masks and working from home.
The cost of addressing these challenges is formidable. The chancellor of the exchequer, Rishi Sunak, set aside an extra £5.9bn for the NHS in his Autumn Budget in October. The money is intended to help clear the record backlog of people waiting for tests and scans, which has been worsened by the pandemic, as well as to buy equipment and improve IT. This is in addition to the £12bn announced in September, to be raised through increases in National Insurance and, from 2022, the Health and Social Care Levy.
This is the biggest increase in core capital investment in health since 2010, according to the Treasury. Paul Johnson, director of the Institute for Fiscal Studies, said the increases in departmental spending have “more in common with Blair and Brown than Cameron and Osborne”. About 44% of the cash increases in the Autumn Budget will go on the NHS over the next three years, the IFS estimates.
However, many question if even this colossal amount will be enough, given the health sector’s structural weaknesses – staff shortages, crumbling buildings, failing social care, lack of equipment and outdated technology. There are currently around 100,000 vacancies across the NHS. Many staff are isolating because of Covid-19, putting further pressure on an already overstretched workforce.
“The significant increase in capital funding will help the NHS reduce the elective care backlog, carry out more tests, reduce health inequalities and contribute toward the NHS net-zero target,” says Danny Mortimer, deputy chief executive of the NHS Confederation.
“But to ensure the extra money delivers for the public, a strong and supported NHS workforce is needed. This is why training and increasing the supply of doctors, nurses and other health and care professionals is so important at a time when public polling recognises that staffing is the biggest problem facing the NHS.”
According to Jeremy Hunt, the former health secretary, “the extra money for the NHS will unravel quickly if we do not train the extra doctors and nurses needed.”
At this critical juncture, the health service is led by two people newly appointed to their roles. Sajid Javid, a former chancellor, became health secretary in June, succeeding Matt Hancock. Amanda Pritchard became chief executive of NHS England on August 1, succeeding Sir Simon Stevens, who stepped down after more than seven years. Pritchard was previously chief operating officer for two years, having worked for the NHS for her entire career.
Together, Javid and Pritchard must navigate the health service through this most turbulent period. In an early sign of the difficulties they will face, Javid courted controversy with a £250m financial package for GPs, linked to measures to increase the number of face-to-face appointments with patients.
Under the new scheme GP practices will be told they must “respect preferences” for face-to-face appointments and should consider using the cash to extend opening hours and offer walk-in consultations to increase the availability of in-person consultations. Those failing to offer sufficient in-person appointments will be denied access to the fund.
Official figures show that 58% of GP appointments in England in August were face-to-face. Before the pandemic, 80% of appointments were carried out in person.
The package has caused anger among GPs, who say the investment falls short of what’s needed while failing to recognise the long hours they have worked to meet patients’ needs during the pandemic. The British Medical Association (BMA) GP committee urged practices not to comply with “the very worst aspects” of the plan, including target-driven league tables. The committee also called on GPs to take steps towards industrial action.
Dr Richard Vautrey, the outgoing chair of the BMA’s GP committee, says GPs have no alternative but to take the action. “All efforts to persuade the government to introduce a workable plan that will bring immediate and longer-term improvement for doctors and their patients have so far come to nought.”
Part of the explanation for GPs’ anger can be traced to the beginning of the pandemic, when NHS policy – supported by the government – was to promote virtual services wherever possible. Digital First was adopted as policy and written into the NHS Long Term Plan, with incentives to invest in new technologies. The Department of Health and Social Care gave enthusiastic support to private digital pioneers like Babylon, which manages “GP at Hand”, the NHS’s app-based service.
Yet the adoption of technology, particularly around the remote delivery of care and support, is critical to the sustainability of the NHS, not just by GPs and primary care but across all services. Investment in technology is a clear focus of the new capital spending supported by the Treasury. Around £2.3bn of the additional funds promised by the chancellor are earmarked for investment in digital IT. There will be a particular focus on creating additional capacity for diagnostic tests, like CT, MRI and ultrasound scans.
Dr Murray Ellender, co-founder and CEO of eConsult, believes funding should be prioritised for digital triage, to give patients the most direct possible route to needed care.
“Cash injections like these may help with easing the immediate blow. But our healthcare system desperately requires a careful overhaul,” he says. “The pandemic has made it clear that the entire system is built on a flawed infrastructure of insufficient and disconnected triage. If we don’t invest in this widespread change now, we not only face a bleak winter, but we may witness the ultimate breaking point for our NHS.”
In healthcare, digital infrastructure is about more than the interface with patients: it’s also about what goes on in back offices. Increasingly, automation is being implemented in areas like referrals. It helps ensure that patients are seen as efficiently as possible, validating their data on the waiting list so they’re set at the right priority and confirming that they still require care. Digital workers are completing similar processes to overcome the cancer care backlog by auditing key milestones across cancer pathways.
IT infrastructure must be an early priority for the new integrated care system (ICS) concept if it is to deliver joined-up care. These systems bring together organisations across the NHS, local councils and the voluntary sector, who will need to share information to establish effective collaborative projects. This will mean creating common frameworks that somehow bring together the multiplicity of IT systems currently being used.
Guidance published by NHS England and NHS Improvement requires each ICS to have “smart digital and data platforms” in place by April 2022, when ICSs will be put on a statutory footing. By then, each ICS should have a senior executive with responsibility for governance and accountability for digital strategies.
Shared care records and cross-system data sharing will underpin the core purpose of ICSs, with an ambition for patient records to travel seamlessly from one provider to another without delay. However, putting this into practice across each ICS requires significant investment and careful planning to ensure that systems are effective and secure.
It’s easy to be cynical about the NHS and healthcare technology, given patients’ experience of lumbering IT in hospitals and GP surgeries. But there is another side, which includes world-leading genome sequencing and the rapid development of the Covid-19 vaccine. The NHS App is currently the most downloaded free app in England. Users benefit from easier access to NHS services, including GP appointments and repeat prescriptions.
Barts Health NHS Trust Health Centre, the largest in the UK, uses a digital system that helps patients and their clinicians connect through virtual appointments. The system captures biometric data, such as blood pressure and heart rate; healthcare professionals can intervene if needed by communicating directly with patients through the service. Patients also have access to data like medical documentation and clinical notes that supports the management of their long-term conditions at home.
But in its quest for a sustainable future, the NHS faces a challenge. It must find a way to harness the information it collects for the benefit of millions of patients and service users. As waiting lists continue to grow and the service struggles to recruit and retain the health and care professionals it desperately needs, this future can’t be taken for granted.
“To truly meet the scale of the challenge over the longer term, government needs to shift the focus to creating the conditions that keep people healthy in the first place,” says Charles Tallack, assistant director of the Research and Economic Analysis for the Long Term (REAL) Centre at the Health Foundation. “This means implementing a whole government approach that places improving health at the front and centre of all major policies.”
NHS shake-up aims at joined-up care
Health and care services in England are undergoing their biggest reorganisation in a decade, thanks to the creation of integrated care systems (ICSs). These are partnerships that bring together providers and commissioners of NHS services across a geographical area with local authorities and voluntary organisations to collectively plan health and care services.
The central aim of ICSs is to integrate care across different organisations and settings, joining up hospital and community-based services, physical and mental health, and health and social care. The expectation that standards of care would be improved by competition among providers has been swept aside in favour of collaboration. The ambition is to remove barriers that often stand between patients or service users as they try to access the care or support they need.
All parts of England are now covered by one of 42 ICSs. Chairs and chief executives have been appointed and the Health and Care Bill currently before Parliament is expected to put ICSs on a legal footing by April 2022, with formal powers and governance structures. Existing clinical commissioning groups (CCGs), groups of GPs previously responsible for commissioning services, will then be folded into ICSs.
There’s no blueprint for developing an ICS. In contrast to many previous attempts at NHS reform, national NHS bodies have so far adopted a relatively permissive approach, allowing the design and implementation of ICSs to be locally led within a broad national framework. As a result, there are significant differences in the size of systems and the arrangements they have put in place, as well as wide variation in the stage of development each system has reached.
A number of ICSs are developing new models of care which benefit patients. For example, in West Yorkshire and Harrogate almost 4,000 patients have avoided unnecessary hospital appointments and received specialist support while remaining in primary care after three hospitals and 64 GP surgeries established a new Shared Referral Pathway. Surrey Heartlands ICS set up the Tech to Connect scheme with local partners, supporting digital literacy. Frimley Health and Care implemented schemes to bring rapid support to the most vulnerable communities during the pandemic, including Black, Asian and minority ethnic groups at greatest risk.
Will ICSs make a difference? While there’s widespread support for joining up services across the NHS and broader collaboration with the local councils responsible for social care, there is uncertainty about how this will be achieved in practice.
For example, the BMA thinks the positive elements of CCGs – such as a strong clinical voice, local decision making and accountability to clinicians – must be kept in ICSs. In particular, it highlights the voice that CCGs have given GPs within local health and care systems.
Meanwhile, The King’s Fund think tank warns that evidence from previous attempts to integrate care indicates that these reforms will take time to deliver results, and that local and national leaders need to make a long-term commitment to change.