The NHS employs 1.5 million people in England yet still does not have enough staff to meet the needs of the working class. The NHS Long Term Plan does not show how this staffing crisis will be sorted despite its urgency. Across NHS hospitals, community and primary care settings, there are about 150,000 doctors and over 320,000 nurses and midwives, a third of the total workforce. One in 12 posts are vacant in hospital and community services. Between July and September 2018, there were 94,000 full time equivalent advertised vacancies in hospital and community services, nearly 40,000 of them in nursing and midwifery.
However, it is in primary care where the staffing crisis is becoming most acute, and where the consequences – ever-lengthening waiting times for appointments – are being felt most. The most recent data shows that there were 27,495 GPs in England in September 2018 (excluding locums, trainees and those undertaking only a small amount of clinical work). This is 1.4% lower than the estimated figure for September 2017, and 6.1% lower than in September 2015. In 2015, the then Health Secretary Jeremy Hunt pledged to increase the full-time equivalent (FTE) GP workforce by 5,000 by 2020/21, using the 34,592 FTE GPs in September 2015 as a baseline. The current Health Secretary, Matt Hancock, abandoned the pledge in autumn 2018; at present, one in five trainee GP places are unfilled. The 3,000 that are filled will be insufficient to address a position where a third of existing GPs plan to retire in the next five years. Overall, the number of GPs per 100,000 people fell from 65 in 2014 to 60 in 2018.
The decline in GP numbers has been more marked in more deprived areas with on average 1,869 people on GP lists in the least deprived fifth, compared to 2,125 in the most deprived. There are also significant regional variations in filled trainee GP posts with almost half of posts in the north east being unfilled. Elsewhere in primary care, general practice nurses have remained static in number but a third are over 55 years old and close to retirement. There have been dramatic falls in district nurse numbers, down by a third since 2009, school nurses, by a quarter, and health visitor numbers have dropped by 20% in the last three years to just over 8,000.
This means increasing difficulty getting an appointment in primary care. In March 2019, of an average 24.2 million daily appointments, 3.3 million were delayed by more than 15 days, and 1.1 million by more than 28 days. In all, one in three patients are having to wait more than a week for a GP appointment. GPs are now seeing up to 60 people a day, clearly with insufficient time and energy for each person. This worsens recruitment problems, and leads to more attendances to A&E as GP appointments become impossible to get in a timely manner. In 2018, more than a million people were left without urgent on-call GP cover on some weekends and nights due to insufficient GPs to staff out-of-hours services. Rural West Wales, Tower Hamlets in east London and North East Lincolnshire were particularly affected.
Across the NHS, more staff are needed because there is both a growing population, and an increasingly ageing population. But there is no real plan for increasing the numbers in clinical training. In particular the number of nurses in training has dropped significantly since early 2000s. Between 2012 and 2018, the number of nurses and health visitors leaving the NHS increased by 25%. Almost 50% of nurses are over 45 years old and a third of midwives are over 50 and can consider retiring at 55. With no reversal in the trends seen currently, there are estimates that there will be a shortfall of 250,000 in NHS staffing by 2030. Along with primary care, mental health services are particularly affected. Registered mental health nursing posts dropped 11% since 2009 and too few newly qualified doctors are choosing to train in psychiatry with one third of consultant psychiatrists not employed substantively by the NHS after completing their training.
Clinician shortages mean that hospitals and GP practices are desperate to recruit from outside the EU given that so many EU staff are now leaving the NHS as a result of Brexit. But doctors from outside the EU are charged so much for working in the NHS that many are currently considering leaving. They face visa charges of thousands of pounds, to which has to be added the Immigration Health Surcharge (IHS) which has just doubled from £200 to £400 per year for each family member. There are over 81,000 doctors out of 300,000 on the British General Medical Council register who got their medical degree outside of the European Economic Area (EEA), while 32,000 come from within the EEA. While it is clear that the NHS cannot provide enough doctors to fill the gaps, the Home Office is equally clear that there should be no exemptions from the surcharge, saying that the ‘income from fees charged for immigration and nationality applications play a vital role to run a sustainable immigration and nationality system’. These charges are applied irrespective of whether the doctor has been trained in Britain. So for example, a doctor in training to be a GP, originally from Malaysia but trained in Britain, faces a fee of £4,200 for a new visa for three years and £400 per year per person in the family for the IHS.
The staffing crisis in the National Health Service is worsening and the real-term squeeze on NHS funding means that there are no answers to it. There is no capitalist solution for providing adequate health services to the working class even in a rich imperialist nations like Britain.
Hannah Caller
