Change seems to be the only constant in the UK healthcare landscape and it is a change that is seminal, sweeping and striking as England and other parts of the UK move into a “post-Covid restrictions” world. We will survey some of the most notable developments within the NHS and take a brief look at broader policy initiatives trailed by the government.
Covid Here to Stay
Whether or not it is a post restrictions world we are moving into across the whole of the UK(this is de facto the case in England as any trip into `London will unveil a largely maskless milieu), it is clear, from the statistics and from the authors’ conversations with numerous NHS chief executives that Covid is alive and kicking.
It has been reported (by the Health Service Journal on 8 March 2022), for example, that the number of covid cases has begun to rise sharply again in English hospitals after falling for 2 months. Some 7709 covid positive patients were admitted to hospital in the seven days to 5 March; this represents a 16% rise from the previous week and is the steepest rise since 6 January.
Plaudits for Vaccination Programme
Notwithstanding these worrying figures, the government has been able to bask in some glory from the recent National Audit Office Report, which has hailed its handling of the Covid vaccine rollout. The NAO applauded the vaccine rollout (which cost £5.6billion) stating that it has been value for money, highlighting that only 4/% of doses had been wasted, far lower than the initial assumption at the planning stage of 15% to 20%.
And before we leave the Covid backdrop, it is important to note that the Prime Minister (who announced a public inquiry into the Covid pandemic and its handling of it in May 2021) confirmed earlier this month that it would be chaired by Baroness Hallett, a retired former judge on the Court of Appeal. It will commence its work shortly, although public hearings are not due until 2023.
While we must await the outcome of the Public inquiry, early portents from reviews of the Government handling of the pandemic do not augur well. On 23 March this year, the House of Commons Public Accounts Committee published a report that concluded that the government was underprepared for the pandemic.
There are three key areas across healthcare that have dominated media and commentary over the past quarter and indeed arguably for much of the pandemic, if not longer.
People: NHS Workforce
On Christmas Eve 2021, the operational and planning Guidance for the NHS was published, and this covered the 2022/23 period.
The number one priority was workforce investment which included “strengthing the compassionate and inclusive culture needed to deliver outstanding care.”
There were 9 other top priorities, including addressing the elective care backlog within the NHS and the imperative to return to pre-pandemic levels of productivity; each is discussed further below.
The most striking themes from within the “People” focused arena over the past few months centre around the need to ensure there is sufficient staff to meet current and projected demand, that their well-being is supported, and a clear plan around delivering this.
The NHS was facing over 100,000 vacancies across all occupation groups as it went into the pandemic in March 2020. However, there has been some positive news in terms of overall staff numbers since then. Helen Buckingham, Director of Strategy at the Nuffield Trust, confirmed that the NHS had seen an increase in staff numbers “..including 23,000 additional nurses over the last two years” but added that “…there continue to be severe shortages across the health and care system.”
Elsewhere there was a warning from the Royal College of Physicians (reported in The Guardian) that the NHS is “woefully unprepared” to deal with the rapidly ageing population in the UK as analysis of ONS stats show England has only one geriatrician to care for every 8000 elderly people.
The RCP joined over 100 medical organizations in calling for an amendment to the Health and Social Care Bill so that there is a requirement on ministers to publish regular assessments on the number of staff in both the NHS and social care
Staff well-being and burnout
Recent months have again highlighted how the healthcare workforce is stretched in light of the demands placed upon it over the course of the pandemic and due to long-established shortages. For example, in the week ending 2 January 2022, across Acute hospitals, there were an average of 80,000 staff absent daily, an increase of 13% on the previous week.
The Health and Social Care Select Committee reported in June 2021 highlighting the emergency situation across health and social care staff in terms of burnout.
In light of this, it is worrying to note that on 21 March 2022 more than 40 NHS leaders in London wrote to NHS staff, warning of the “dangerous level” of abuse many now have to confront.
In light of these challenges (and there are many others, including pay levels and the significant work still to be done in terms of inclusion and attacking discrimination within the NHS) there have been widespread calls for a true workforce plan that takes account of anticipated demand for services over the longer term.
Workforce plan and planning
And now it has now been confirmed, by Health Secretary Sajid `Javid, that across “NHS England and Health Education England (HEE), work is being undertaken to create such a plan.
Dr. Navina Evans, CEO at HEE, confirmed that a long-term approach to workforce planning is being taken: “The longer-term planning framework promises the most. This is why HEE is working with Skills for Care, think tanks, providers, staff, students to create a framework for workforce planning 15 years out, for the first time covering both health and social care.”
The real challenge for many in the sector is that notwithstanding the trailing of such a plan, the Health Secretary has confirmed, in a much-anticipated speech in March 2022, that no new funds will be made available for increasing staff levels which the workforce plan may recommend. He added that any such increases would need to be funded from existing budgets.
It is instructive to recall the comments from NHS Providers (responding to the Spending Review in October 2021 ), which stated that it was “difficult to see how benefits will be delivered without a fully funded workforce plan to address shortages.”
Chris Hopson, the `CEO at NHS Providers, spoke with candour about what any workforce plan must address: “The NHS’ position is absolutely clear. It is impossible to run the NHS effectively without a numbers-based plan that runs beyond the spending review.”
Patient Care Delivery
Having sufficient numbers of workers, clinicians and non-clinicians is the predicate upon which the vision of the NHS Long Term Plan 2019 rests. It is also the basis upon which there is pinned the hope of clearing the unprecedented backlog of elective care. The 2022/23 Planning Guidance’s top 10 priorities included the imperative to deliver “significantly more elective care to tackle the elective backlog.”
The data from the latest NHS updates paint a very bleak picture of the current operational challenges facing the NHS.
In January 2022 for example, 38% of patients with an urgent GP referral waited for more than 2 months for their first treatment of cancer. Furthermore, as of January 2022, the waiting list for people waiting over two years for consultant lead treatment grew to 23,778; this is more than 8 times the number In April 2021.
This must also be seen in the context of record numbers of people awaiting elective care treatment; at the end of December 2021, 6.07million patients were waiting for “elective care,” the biggest waiting list on record. The actual number of people seeking or needing elective care could be higher given that large numbers of patients did not attend or were unable to access routine NHS services during the pandemic.
Against this context, much attention has been given to the publication ( on 8 February 2022)by NHS England of its elective recovery plan entitled “Delivery Plan for tackling the Covid-19 backlog of elective care”.
The plan set bold targets but admitted that waiting lists for elective care could continue to grow until March 2024. It did, however, add that by July this year, no patient will wait longer than two years for elective care.
Sir Jim Mackay, National Director of Elective Recovery at NHS England,in the days following the plan’s publication, took the opportunity to highlight that the NHS now faces a “much more performance management-orientated world”. Jim’s candour is refreshing and the author remains indebted to him for being interviewed as part of the preparation for writing the LaingBuisson UK Healthcare Workforce Report 2021.
Commenting on the recovery plan, Richard Murray, Chief Executive of The Kings Fund, stated, “This is a welcome plan, but the NHS will need more staff to make it a reality.”
Performance: Financial Imperatives
A further key part of the (complex and ever-moving) jigsaw that is NHS “recovery” in a “post” Covid world relates to the level of resources it will have to meet growing demand over the next few years and beyond. The Operational Planning Guidance for 2022/23 requires NHS Trusts to return to “pre-pandemic” levels of productivity and this, of course, implies far greater efficiencies in the use of resources.
The Spring Statement from the Chancellor, Rishi Sunak, delivered on 23rd March 2022, unveiled a number of policy initiatives to tackle wider macro challenges (especially relating to once in a generation cost of living pressures on UK families), but it included a clear call for eye-watering improvements in the efficiencies demanded of the NHS
Indeed as the chancellor himself put it “we are doubling the efficiency target for the NHS”. In terms of detail, this means that the NHS’ annual savings target will now stand at 2.2%, and it has been reported that this could deliver savings of close to £4.75billion.
This call has been met with some alarm from the NHS. Chris Hopson, the chief executive of NHS Providers, highlighted that `Trusts were already under great pressure to deliver savings saying “it is striking how many trusts are telling us that they are concerned by the scale of the efficiency savings they will need to realise.”
It is important to note that research has shown that the long-term savings secured by Trusts prior to the pandemic stood at 1.1% annually on average.
The broader effect on the ability of the NHS to deliver on its imperatives (including no doubt the ability to attract and retain staff which includes having to offer attractive pay levels ) by the above efficiency demands will remain to be seen; particularly as rising inflation erodes the real term funding increases for the NHS announced in October 2021’s Spending Review.
No Respite in Reform: Integration, Primary Care and Leadership
We have only a very brief space to refer to the fact that the appetite for sweeping further reform of UK healthcare shows no sign of being satiated. The range of policy (potential or soon to be promulgated) initiatives is striking.
This includes the Health and Social Care Bill, which is making its way through the legislative process and is the foundation for a fundamental transformation of the very decision-making landscape across healthcare. The Bill also enshrines the Health and Social Care Levy and the lifetime cap on Social Care costs, each likely to profoundly impact the nation’s health and well-being and access to services for decades.
Of particular note from the legislative process is news that the government has approved some key amendments relating to mental health, and this includes the call for more transparency on mental health funding. In addition, the amendments include the need to require the definition of “health” to include mental health.
Other notable (and potentially transformative if not disruptive) initiatives include a Report on primary care where Policy Exchange has recommended the possibility of GPs becoming full-time employees within the NHS (something which Health Secretary Sajid Javid seems to be looking upon with some approbation).
Finally, the review of health and social care leadership (led by General Sir Gordon Messenger) is expected to report soon. The King’s Fund has described this review as “the first detailed examination of social care leadership in England there has ever been.” Given the importance of leadership for all three of the major themes we touched upon above (People, Patients, Performance), this could be a report with profound longer-term implications for the sector