meAt a television studio in Stoke-on-Trent last month, Liz Truss and Rishi Sunak traded blows about everything from the credit card economy to the Channel immigrants to the Claire’s accessory chain. The list of problems the couple faced was dizzyingly long.
However, there was one glaring omission. In the hour-long debate there was not a single mention of the NHS, despite it being mired in the biggest crisis in its history. The NHS now shares the same characteristics as many who depend on it to keep them alive and well: they are elderly, have multiple co-morbidities and are in dire need of emergency care. Summer has brought her to her knees. The worst is expected this winter.
“The new prime minister will inherit an NHS in its worst state in living memory,” says Matthew Taylor, chief executive of the NHS Confederation, which represents the health system in England, Wales and Northern Ireland. “There is no escaping that the NHS is in a state of crisis.”
The facts, he says, speak for themselves. “There are 105,000 vacancies. Urgent and emergency services are overcrowded. Around one in seven hospital beds are occupied by patients who cannot be discharged. Some patients have had to wait more than 40 hours for an ambulance. Attention is being put at risk by neglected buildings due to lack of investment. And then there are the waiting lists, which stretch into the millions in elective care, mental health and community care.”
Jeremy Hunt, chairman of the health and social care committee, is equally concerned. “The new prime minister will inherit an NHS facing the most serious crisis in its history,” he warns. “A&E, ambulance, general medicine, and social care are in serious jeopardy across the country.”
The main problem for the new incumbent of Downing Street is that, whereas in previous years the problems in the NHS were focused on specific areas, today the whole house is on fire.
“The NHS has never been more challenged than it is now,” says Alastair McLellan, editor of the Health Service Journal. “There isn’t an area of NHS provision that isn’t really struggling… There is literally nowhere that it isn’t bad and in some cases really bad.”
In the short term, says Robert Ede, chief of health and social care at the Policy Exchange think tank, the key task will be setting priorities. “Almost all the dash lights are flashing. The singular priority for this winter should be ensuring that patients can access basic services.”
One light that shone all summer was urgent and emergency care. A record 29,317 people had to wait more than 12 hours in English A&E departments in July since the decision to admit they were actually admitted. That was 33% more than the previous month’s 22,034 and is the highest for any month in records going back to August 2010.
“Patients face extremely long wait times,” says Dr Adrian Boyle, vice president of the Royal College of Emergency Medicine, who says many are in serious condition or seriously injured. “We know that long wait times for patients can cause harm or worsen conditions or injuries. The sheer number of patients waiting for care is alarming.”
Ambulances in England took an average of 59 minutes and seven seconds last month to respond to emergency calls, such as strokes, up from 51 minutes and 38 seconds in June, well above the target of 18 minutes. “If you call an ambulance in the Southwest…there’s a reasonable chance you’ll be dead before it shows up,” says McLellan. “As bad as the NHS has gotten in the past, that hasn’t been the case.”
Richard Murray, chief executive of the think tank King’s Fund, agrees. “While the waiting list that crossed the 6.7 million point may seem surprising enough, the depth of the challenge in emergency care, seen in ambulance and emergency room wait times, is worse. NHS recovery plans have been hampered by repeated waves of the Omicron variant and, more fundamentally, by deep labor shortages that have been brewing for a long time.
The general practice has been particularly affected by the failure to recruit and retain enough staff. “Too many patients say it’s hard to get a GP appointment even though primary care colleagues are working flat out,” NHS England chief executive Amanda Pritchard admitted in a memo to staff this month. .
In 2015, the government promised to recruit a further 5,000 GPs over five years, but the number has decreased rather than increased. In 2019, the government promised a further 6,000 GPs by 2024, but progress has been very slow.
“The new prime minister must make general practice a top priority if he is to ensure the NHS remains sustainable to deliver patient care now and in the future,” says Professor Martin Marshall, president of the Royal College of GPs. “We are doing more consultations each month than before the pandemic and the care we provide is becoming more complex, but the number of fully qualified full-time GPs is declining.”
Christina Pagel, a professor of operations research at University College London, says Covid-19 “significantly worsened” the NHS crisis, but did not cause it. “Essentially, we entered the pandemic with a health service that was already cut to the bone, severely understaffed, morale issues and underfunded.” Nigel Edwards, CEO of the thintank Nuffield Trust, agrees. “The pandemic has added fuel to the fire, but the root of these problems has been decades in the making.”
Dr Subramanian Narayanan, chairman of HCSA, the hospital doctors’ union, says the NHS is in a worse position to deal with a pandemic now than it was in 2020. “Staff shortages are more severe than at the start of the pandemic and there are there is no evidence that the drivers of this are being addressed.”
The labor crisis is the main problem. “Warnings about the lack of a plan for health care staffing have been out there for years,” Pagel says. “Brexit made it much worse, particularly in the cities, as we lost so many EU staff who chose to go home.”
Pat Cullen, general secretary of the Royal College of Nursing, which will vote its members on industrial action next month, says the key to solving the NHS crisis is through “recruitment and retention, and this starts with paying staff fair way.”
With a renewed focus on ambulance delays and care backlogs, other areas of the NHS are slipping. Mental health is an alarming example. “Mental health has, in recent years, made its way up the agenda,” says McLellan. “And the standard of investment in mental health, while not perfect, actually saw more money spent on mental health. Mental health was getting there… my feeling now is [it’s] actually going backwards.”
Saffron Cordery, chief executive of NHS Providers, says mental health services have become overwhelmed. The Royal College of Psychiatrists warns that waiting lists are at record levels and that care is at a “crisis point”. The YoungMinds charity says thousands of young people are attempting suicide as a result of long waits for treatment.
“The NHS has never faced such a deep crisis and there seems to be no political will to face reality and control it,” says Boyle. “It is deeply worrying that neither the prime minister nor the leadership candidates have grasped the seriousness of this crisis, the scale of patient harm that is occurring and how much worse it could get in the winter.”
Since its absence from the Stoke-on-Trent debate, the NHS has barely featured in the leadership race. He only did so recently when Truss said he would divert £13bn of NHS funding to social care.
In theory, it’s a good idea, says McLellan, but it should have happened years ago. The problem now is a “dangerous time to do it.” “Does social care need more money than the NHS? yes. But now we’re in a situation where they’ve let the NHS go into crisis, as well as social care. So they both need money.”
Difficult decisions must be made, says Edwards. “The new prime minister will need to quickly confront and make tough decisions to address interconnected challenges in health and care if he hopes to reverse declining performance, declining public satisfaction and growing inequalities in access.”
That means urgent action, Murray emphasizes. “What can be done? Winter is always by far the most difficult time for the NHS, and time is desperately running out to do anything, but whatever can be done, must be done.
“This includes supporting vaccination campaigns against covid and flu; produce a quick solution to the pension problem that drives senior staff out of the service; and be prepared for emergency social care support which can also help the NHS by getting patients out of hospital quickly when they are ready. Beyond that, sustainable recovery can only come from addressing the workforce crisis.”
Hunt says: “We have a horrible winter ahead of us, and a serious, funded NHS workforce plan is the only way to prevent preventable deaths from piling up in the coming months.” Ede argues that urgent investment in NHS capital, such as new kits and facilities, “has the potential to deliver a much higher return – solving problems like delayed diagnosis”.
Meanwhile, the NHS crisis and the choices facing the new prime minister come at the worst possible time, says Edwards. “These decisions will be made even more difficult in a context of 1990s austerity, a shortsightedness reminiscent of 1980s and 1970s labor relations and inflation. There will be no easy route through.”