Providing equitable access to high quality care is the driving mission of the NHS. It's enshrined in the constitution of the health service and it's what motivates NHS leaders and staff every single day.
However, for over a decade, there have been a number of clear risks threatening the sustainability of the NHS, including a lack of national workforce planning, growing health inequalities and insufficient investment to meet growing and changing patient need.
For some time the NHS appeared to cope with these combined pressures. Until 2019, patients continued to report positive experiences of their care, public satisfaction with the NHS remained high, and while some performance targets had been missed for several years, elective waits remained low and ambulance response times were broadly on track. But NHS Providers warned that trusts could not continue to meet these challenges indefinitely if long-term issues like workforce were not addressed.
Trust leaders are working harder than ever to provide safe and effective services, but for many the winter just gone was the hardest they have ever experienced – and the pressures continue.Policy Advisor (Quality)
Now, the cumulative effect of those continuing pressures – exacerbated by the pandemic – is all too plain to see. The latest performance figures show the elective care waiting list has reached its highest ever level at 7.4 million people, alongside care backlogs in mental health and for some community services. Operational performance for ambulance services and emergency departments remains well below the targets staff and trusts are striving for, and key cancer targets continue to be missed. Meanwhile, Care Quality Commission and other national surveys show that patient experience has noticeably worsened in recent years, and while the public's commitment to the founding principles of the NHS continues to hold, the British Social Attitudes survey found that public satisfaction with the NHS fell to an all-time low in 2022.
Trust leaders are working harder than ever to provide safe and effective services, but for many the winter just gone was the hardest they have ever experienced – and the pressures continue. Despite their best efforts, our members tell us that they are concerned about staff morale and burnout, and that the demand placed on many services, coupled with staff shortages means increasing risk to care quality and to patient safety.
It is worrying to hear from trusts that they are not always able to maintain the staffing ratios that they would like, and that their staff feel unable to provide the level of care that they and their patients expect.
Trusts are doing everything they can to try to relieve these pressures and maintain quality of care, like working in partnership to share resources more effectively in response to capacity shortages, improving local recruitment practices or focusing on staff experience. But equally, sometimes managing these risks means difficult trade-offs, such as having to postpone activity to maintain patient safety in the short term, or providing care in suboptimal environments.
Developing a culture of improvement can help to combat the risk of a normalisation of lower standards.Policy Advisor (Quality)
In circumstances like this, the efforts that many trusts have put into developing a culture of speaking up, and the infrastructure that supports this, is vital. It's more important than ever that people working in trusts, as well as the patients they serve, are secure in raising concerns about the level of care being provided or if things go wrong, to support continuous learning and improvement. So too will be the implementation of new national patient safety systems which will support trusts to learn from incidents and involve patients and families as they do so.
Nevertheless, even with these efforts, we know that it is immensely challenging in the current climate for boards and NHS staff to focus on doing things differently and improving care.
There are other encouraging signs. Recently, NHS England launched a new programme called NHS Impact, which will provide a set of principles for improvement that all NHS organisations are expected to follow, along with support to develop their improvement capability.
This is a positive step forward. Properly embedded within an organisation and supported by a culture of continuous improvement, healthcare improvement approaches can make a real difference to quality of care, patient safety and patient experience – even under challenging circumstances. And developing a culture of improvement can help to combat the risk of a normalisation of lower standards and remind staff, struggling to see the light at the end of the tunnel, that with the right tools and focus, things can be different.
Providing high quality care is the driving mission of the NHS, and that mission hasn't changed. But the risks to that are now clearer than ever.Policy Advisor (Quality)
We particularly welcome targeted support to trusts who have less expertise and experience in this area, and the commitment from NHS England to work differently with trusts, supporting them to focus on sustainable improvement rather than short-term goals like financial control.
However, for the promise of the NHS Impact approach to be truly realised, wider government action is needed and urgently; day-to-day pressures caused by workforce shortages, financial pressures and increased demand cannot be wished away. A high standard of care in a 21st century health and care system requires investment in workforce capacity and capability, and in 21st century estates and equipment.
Providing high quality care is the driving mission of the NHS, and that mission hasn't changed. But the risks to that are now clearer than ever. And we need to be just as clear in recognising that NHS trusts can and want to deliver for their patients – but being able to do this means giving them the support they need.
This opinion piece was first published by Public Sector Focus.