The NHS – something now has to give
Despite the best efforts of hardworking NHS frontline staff, hospital accident and emergency performance is now the worse it has ever been. In the first three months of 2016 only four of the 138 large A&E departments saw the required 95% of patients within four hours. One in 10 had to wait more than four hours, the highest level at this time of year since 2003/04.
There is now an unbridgeable gap between what the NHS is required to deliver and the money to pay for it
Waiting lists for operations, with 3.9 million patients waiting for treatment, are now at their highest since December 2007. The three million mark used to be considered a watershed not to cross, but leading experts have suggested that, on the current approach, the operations waiting list target is irrecoverable. There are similar problems of dropping performance against cancer and ambulance standards with mental health and community services under similar pressure.
At the same time, we ended last financial year with trusts reporting the largest deficit in NHS history – £2.45 billion but, in reality, above £3.5 billion once you strip out one-off transfers and accounting adjustments.
These performance and financial challenges are being matched by unprecedented shortages across staff groups central to the effective running of the NHS, including nurses, key specialists, GPs and emergency doctors. These have led to unavoidable closures of A&E departments and other services, unsustainable pressure on GPs and, in 2015/16, an unaffordable extra £3.6 billion agency staff bill.
Demand for NHS services also continues to rise much faster than predicted: between April and June 2016, A&E attendances and emergency hospital admissions were up by more than 6% compared to last year – three times the predicted increase. If funding fails to keep up with this demand, the challenge for the NHS just grows year on year.
Demand for NHS services continues to rise much faster than predicted
These problems aren't just confined to a few geographic areas - they are now affecting the whole NHS. In the first three months of 2016/17, almost all A&E departments (94%) missed the four hour A&E standard. At the end of 2015/16, nearly two-thirds of trusts, and more than 8 in 10 acute hospitals, were in deficit.
The problems the NHS faces are being heightened by a full blown crisis in social care as funding cuts bite, eligibility criteria are raised and private providers leave the market. It’s no surprise that cutting social care year after year has created major problems for the NHS. Given the additional lack of capacity in community and mental health services, the number of patients waiting for a hospital discharge is now the highest it’s ever been. As a result, hospitals are now being asked to routinely run at capacity levels that risk patient safety and would be unthinkable in France, Italy or Germany.
Taken together this means the NHS is increasingly failing to do the job it wants to do and the pubic needs it to do, through no fault of its own.
This concrete evidence is supported by the testimony of frontline NHS leaders. Thanks to the dedication of NHS staff, NHS performance rarely goes off the edge of a cliff. As the 1990’s showed, instead, we get a long slow decline that is only fully visible in retrospect. It’s therefore difficult to isolate a single point in that downward trajectory to sound a warning bell.
But NHS trust chairs and chief executives are now ringing that bell – we face a stark choice of investing the resources required to keep up with demand or watching the NHS slowly deteriorate. Trusts will, of course, do all they can to deliver what’s required, including an ambitious level of efficiency savings and productivity improvements. But they are now saying it is impossible to provide the right quality of service and meet performance targets on the funding available. Something has to give.
Particularly since NHS funding increases are about to drop from 3.8% this year to 1.4% next year and 0.3% in 2018/19. As total NHS demand and cost rise inexorably, by at least 4% a year, this will mean even larger gaps after seven years of the deepest and longest financial squeeze in NHS history.
The NHS is increasingly failing to do the job it wants to do and the pubic needs it to do, through no fault of its own
So what does give? A range of options are now open to political and NHS leaders. Additional funding is the most obvious, with the new government’s first autumn statement on November 23 providing an immediate opportunity.
If, however, there is to be no more funding, the NHS must make some quick, clear, choices on what gives, however unpalatable these choices may be. No-one in the NHS wants to depart from the key principle of care being available to all, based on clinical need, not ability to pay. But if there is a gap, we have to fill it somehow.
The logical areas to examine would be more draconian rationing of access to care; formally relaxing performance targets; shutting services; extending and increasing charges; cutting the number of priorities the NHS is trying to deliver; or more explicitly controlling the size of the NHS workforce. These are all approaches adopted by other public services like prisons, local government and the police when faced with similar funding challenges over the last decade. Though they would clearly provoke public unease and Ministerial anxiety if applied to the NHS.
In reality, individual areas are already having to make decisions like these on a piecemeal basis. For example, in the last three months, clinical commissioning groups like St Helens and Vale of York have developed proposals to suspend all non urgent care for four months or suspend non urgent treatment for obese patients and smokers for a whole year. A number of trusts have had to close services on safety grounds and others have announced plans to reduce the size of their workforce. Unsurprisingly these decisions triggered local opposition and adverse national media coverage.
NHS trust leaders rightly argue that this piecemeal approach is unsustainable. It is not tenable to ask local leaders to deliver the impossible, make unpopular local decisions as quietly as possible and then carry the can when the decisions become public. As the junior doctors’ dispute shows, it is also untenable to ask NHS staff to close the gap by simply working harder and harder.
In the absence of extra funding, we need an open, honest, realistic, national debate on what gives, translating into immediate clear choices, with national leaders explaining why such choices are necessary. Any such debate must extend beyond the NHS and involve the public. The earlier that debate starts and the more open and honest it is, the better.
This article was published by the Observer on 11 September