There is no end to the crisis facing the NHS. Instead, on every indicator, the crisis worsens every week. The number of doctors continues to fall, as do the numbers of nurses. Bonded labour is required to replace some of the lost staff (see box p2). Waiting lists are soaring, with little idea as to when they will peak. Wait times in an ambulance outside A&E, wait times for admission from A&E onto a ward all are at record levels. It is quicker to get a pizza delivery than get an ambulance for a cardiac arrest. Yet we still have the charade where the government proclaims that it is putting more and more money into the service – but out of sight takes the money away.
The passage of the Health and Care Act in April 2022 made no real difference. The government was determined not to impose any legal duty on itself to be transparent about the number of staff needed by health and care services in England – and in the midst of a staffing crisis made sure that was the case. There was the usual NHS reorganisation that such Acts always include: in this instance it put the so-called Integrate Care Systems (ICS) onto a statutory basis. 42 such ICSs cover the whole of England, and are responsible for commissioning health care services as well as ensuring they become an integrated whole where hospital and primary care organisations work together.
The financial crisis
However, this really was shuffling deck chairs on the Titanic. The crisis in the NHS has been created deliberately by the austerity policies of the last 12 years. While the headlines from 2010 onward spoke of protecting the NHS from the cuts imposed on other state services, in reality the flat-line funding during those years did represent a real cut and overall, a reduction of 6% per head of population in spending on health services. The 2021-22 budget slashed Covid-19 funding from £15bn to £3bn – that is, before the Delta and Omicron peaks materialised. Even in March 2022, one in five hospital beds were still occupied by patients with Covid-19 and nearly 2,000 a week were dying from it. Thousands of NHS staff were also having to isolate either because they had the disease or because they had been in contact with someone infectious.
On top of this, the government has told the NHS that its core funding will be cut by £500m in 2022-23, and that it will have to deliver 10% ‘efficiency savings’ for each of the next three financial years. Such is the reality of the £36bn health care ‘levy’ announced with a great fanfare in September 2021. Once £6bn had been subtracted for the devolved governments, the amount earmarked for NHS in England was £15.6bn – spread over three years. Out of this the NHS would have to pay for Covid-19 tests for its staff and patients. Hence a supposed increase in funding turns into a real-term cut. It is generally agreed that NHS spending has to rise by 4% per annum to keep pace with the needs of an increasing population that is also ageing, and with changes in medical technology; this had been more or less achieved between 1960 and 2010. Now the funding shortfall is estimated cumulatively at nearly £200bn, with the 2021-22 budget £33bn below the £189bn it would have been had the 4% annual increase been maintained over the period.
Soaring wait times
The immediate effects of the crisis are the soaring numbers of people who are waiting for NHS treatment. Already a record 4.5 million before the Covid-19 pandemic, there are suggestions that the number of people who need NHS hospital services could be as high as 13 million: they include those who did not come forward during the pandemic because of fear of catching Covid-19 in hospital or reluctance to bother a clearly completely overwhelmed NHS, and those who are experiencing the long-term consequences of Covid-19 of whom there are a known 1.8 million at present. As of February 2022, the number waiting had anyway risen to 6.2 million, 300,000 for over a year, and is increasing by 20,000 per day. This number includes 570,000 women in Britain waiting to see a gynaecologist, of whom 25,000 have been waiting over a year, up from 66 before the pandemic.
While the government piles the pressure on the NHS to deal with the backlog of elective cases, there are no moves to make up for the 5,000 hospital beds lost out of 98,000 as hospitals reorganised to accommodate Covid-19 patients separated properly from non-Covid-19 patients. But then the extra beds would require extra staffing – and there are at least 110,000 vacant posts across the NHS. Meanwhile approximately 13,000 hospital beds daily are occupied by patients who are medically fit for discharge, but have no suitable social care arrangements in place.
Emergency care
‘Urgent and emergency care is in a deeper crisis than ever before’, says Katherine Henderson, president of the Royal College of Emergency Medicine, who warns that it is becoming impossible in some places at some times to reach seriously ill people promptly after they dial 999, and treat the sickest in a timely way. The system cannot cope with the increasing demand as people come forward after two years of the pandemic. In March 2019, the number of patients waiting more than 12 hours in A&E following a decision to admit them into hospital was 331 when there were 2.17 million people going to A&E; in March 2022, the number of 12-hour waits was 22,506 from the same number of A&E attendances. There is a current shortfall of 2,500 A&E consultants. Henderson says ‘the true barrier to tackling this crisis is political unwillingness’.
In April 2022 Henderson said the delays to emergency care were putting lives at risk. The Royal College of Emergency Medicine’s study revealed that 80% of clinical leads in emergency departments across the country reported ambulances being held in a queue every single day in a week in April, a 15% increase compared to December 2021. 55% of clinical leads in April reported a longest stay in A&E of over 24 hours, and almost a quarter (23%) said the longest stay was over 48 hours.
These delays have a catastrophic effect on ambulance response times: because A&E departments are full, ambulances with emergency patients on board have to queue outside before they are able to offload them. In April 2022, there were nearly 19,000 instances where a handover was delayed by 30 minutes or more, double that for the equivalent period in 2019. This means that ambulances are not available to respond to emergency calls within target times. So-called Category 1 calls supposedly have to be responded to within seven minutes: the average now is nine minutes while response times to Category 2 calls which include stroke victims average more than 50 minutes, and those for Category 3 and 4 calls stretch into hours.
General practice
The World Health Organisation says an average of 25 daily appointments for a GP represents a safe level of care. However, many GPs are currently doing up to 40 appointments. There are now 1,564 fewer fully qualified full-time GPs compared to 2015. NHS Digital showed that GP practices delivered four million more appointments in March 2022 than during the previous month, despite there being 369 fewer full time full qualified GPs than a year ago. At the 2017 Tory Party conference, the then Health Secretary Jeremy Hunt promised 5,000 extra GPs by 2020. It was an egregious example of the many empty promises of Tory governments to address the overall staffing crisis facing the NHS.
Where do we stand
The International Health Care Outcomes Index 2022 showed that health services in the UK have dropped and are now near the bottom in almost every index of international comparison across 18 comparable (ie advanced capitalist) countries. Thus, the UK:
- Is 10th for spending on its health system as a percentage of GDP.
- In 2019 ranked 17th for life expectancy.
- For strokes and heart attacks has the worst survival rates.
- Across five different types of cancer measured by the OECD the NHS comes 16th.
The Office for National Statistics has calculated that men born in the poorest areas of the country are now expected to live almost ten years less than those in the richest areas and women eight years less. Women born in the poorest areas of England live 19 fewer years in good health than those born in the wealthiest areas. There is a continuing trend of worsening health inequalities. The February 2022 government White Paper on Levelling Up says its aim is to improve healthy life expectancy by five years by 2035. The Health Foundation calculates that on current trends it will take 192 years to reach this target. These are the consequences of austerity and an NHS slashed to ribbons.
Hannah Caller and Robert Clough
