The NHS 'crisis' has been years in the making

Fears this winter would be one of the toughest for the NHS are fast becoming reality.

Trust leaders tell us the NHS is in crisis. We are seeing a whole system under sustained and growing pressure as demand for services continues to outstrip capacity.

Urgent and emergency care services are most visibly bearing the brunt of this pressure. Meanwhile, waiting lists for planned care have increased and the physical and mental health of the population appears to have deteriorated as health inequalities widen. None of this was created by the COVID-19 pandemic. The virus' direct impact on our health, as well as some of the measures to contain its spread, may have exacerbated these problems, but to attribute the pressures we see in urgent and emergency care today to COVID-19 alone would be a misdiagnosis.

Since 2010, we have seen a decade of squeezed funding – resulting in a lack of investment in maintaining buildings – a declining number of beds, insufficient diagnostic equipment, failure to grow the NHS' workforce in line with increasing service demand, and a failure to invest in community, mental health and primary care. Diminishing budgets in social care and the stalling of reform have kept delayed discharges stubbornly high, which means people too often remain stuck in hospital when they are medically fit to leave because of a lack of capacity in social care and other community services.

The remaining winter months and well beyond will see NHS organisations continue to face very high demand.

As the NHS continues to work through record demand and manage the ongoing effects of a pandemic, trust leaders are stepping up plans to recover core services, reduce waiting times and deliver the services the public expects from them.

The recent NHS operational planning guidance set out some challenging but realistic expectations. For example, average ambulance response times for serious and life-threatening conditions such as strokes or heart attacks are expected to improve to 30 minutes in 2023/24. Recent performance figures have seen average waits of over one hour. The current target is 18 minutes. The remaining winter months and well beyond will see NHS organisations continue to face very high demand. NHS Providers' recent survey of trust leaders found that 86% of respondents were very worried about meeting demand in 2023.

The current crisis won't be resolved imminently, but there are some immediate steps trust leaders have been taking to manage the pressures more effectively. We have seen many trusts increase initiatives to improve staff wellbeing, including offering financial support to help with cost-of-living increases where possible. While vacancy rates and staff resilience can only be sustainably improved through the national lever of a fully costed and funded workforce plan, local measures can help reduce stress and improve retention in the short term.

Other trusts have undertaken collaborative working arrangements where they share intelligence, data and – most importantly – resources to weather demand across larger geographic areas in "place-based partnerships". While local examples highlight effective practice and show how providers can continue to deliver in the most challenging contexts, there are unavoidable and systemic factors that mean capacity can only stretch so far.

The current pressures on the NHS are born out of a fundamental mismatch between supply and demand across the whole health and care system. Resolving this is key to putting the NHS on a sustainable footing and ensuring that health and care services are operating effectively. However, this is a long-term task.

The crisis we hear about in the NHS today is an historic one.

To their credit, the government and NHS England have made attempts to manage demand, including introducing clinically led system control centres and working with trusts to help reduce ambulance handover delays. But managing demand better will not be enough: equal focus is needed on reducing demand itself by improving prevention and increasing supply of beds and staff.

Improving population health will require a cross-government approach. Tackling the broad array of social and economic determinants of poor health is key, as is investing in more preventative healthcare services such as weight management services or cardio-vascular disease and cancer screening. Increasing bed supply in hospitals and supporting trusts offering virtual wards should also be a priority. The number of hospital beds in the UK has been falling since the late 1980s and is now one of the lowest, per capita, compared to the other OECD countries.

The crisis we hear about in the NHS today is an historic one. It was also many years in the making, so its resolution cannot be found overnight but instead through sustainable, longer-term investment from the government, a clearer focus on supporting the workforce and innovation and commitment from frontline staff and leaders.

This blog was first published by the BMJ.

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