The UK healthcare sector is undergoing a profound transformation and has its third Health Secretary in a matter of weeks (Therese Coffey), after Liz Truss won the Conservative Party leadership election, and became Prime Minister at the beginning of September.
The NHS is facing multiple challenges some of which we discuss below, and this includes clearing the backlog of elective care, adjusting to a new radical statutory organisational landscape amidst the claim (by the Health Foundation) that “public satisfaction with the NHS has fallen to a 25 year low”.
All of these challenges are grounded in the reality of what Jeremy Hunt (Chair of the Health and Social Care Select Committee) describes as the greatest workforce challenge in the history of the NHS.
INTEGRATED CARE SYSTEMS (ICS) – A NEW STATUTORY REALITY
Whilst ICS began as voluntary arrangements, they were placed on a statutory footing in July 2022 pursuant to the Health and Social Care Act 2022. Under its provisions, Integrated Care Boards replaced Clinical Commissioning Groups, NHS England and NHS Improvement were formally merged, and there was a move away from competition within the NHS system toward one informed by the spirit of collaboration. Under the Act, Integrated Care Boards, together with partner Trusts, are required to prepare 5-year plans that are designed to meet local population needs, and that must also demonstrate that the plans break even financially each year. The Act also placed a cap on the amount an adult will be required to pay towards care costs within their lifetime.
Only time will tell whether the raison d’etre of ICS (to create a joint and locally-based approach to the provision of healthcare across the NHS, social care, local authorities, and the voluntary sectors) will become a reality, de facto rather than de jure.
It certainly comes at a time of acute challenge, and the words of the Health Foundation (in July) are echoed with refreshing candour:
“The latest re-organisation of the NHS in England comes at a time of intense pressure on the system. The backlog of unmet needs is growing, and the NHS staffing gap currently stands at more than 100,000.”
PATIENT PRESSURES
Much progress has been made by the NHS with respect to clearing the backlog of elective care; the Health Service Journal stated in late July that the target to eliminate the 2-year waiting list was “nearly in the bag”.
However, it is clear that much remains to be done to meet the extent of unmet needs within the NHS. It was reported within NHS data in August 2022 that only 6 of the 42 ICS were delivering the same or more activity than the pre-Pandemic levels in May 2022. It is to be recalled that the NHS Elective Care Recovery Plan (February 2022) envisaged the health service delivering 30% more elective care activity by 2024-25 than the activity level before the Pandemic.
This should be placed in the broader context of eye-watering numbers of patients awaiting care. The NHS Performance Summary issued by NHS England in the first half of August 2022 revealed that the numbers awaiting elective care had grown and reached 6.7 million people waiting for planned hospital treatment in June 2022; the latest figures show this has increased to 6.8 million. And some 350,000 had been waiting for more than a year to commence elective care.
Looking at more specific patient groups in the same summary revealed that Accident and Emergency waiting times (in July 2022) were the worst since records began, with 29% of people waiting for more than 4 hours from arrival to admission.
In terms of cancer patients, 40% of patients had been waiting for more than 2 months to commence treatment for cancer, following an urgent GP referral.
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STAFF SHORTAGES: “WORST STAFFING CRISIS IN HISTORY”
The dominant theme across all of the health and social care remains the depth and breadth of the staffing shortages, and wider challenges within them. Without addressing staff shortages, meeting the broader policy goals for healthcare in the UK have little hope of being realised.
The numbers reveal a stark picture facing policymakers, as we look ahead to the coming winter months.
The Health and Social Care Select Committee in its July 2022 report highlighted that the NHS was facing a shortage of 12,000 doctors, and a shortfall of more than 50,000 nurses and midwives. Taking a closer look at nurses, we can see that this perhaps is the consequence of many years of challenges facing the nursing workforce. The Health Foundation (examining NHS Nurse Pay in its publication of June 14, 2022) reveals that between 2011-2021, the average basic earnings of NHS nurses fell by 5% in real terms. Furthermore, this fell in real terms by 1.2% a year between 2010-2017, whereas the average earnings across the UK economy fell by 0.6%.
The recent NHS pay award should also be read in light of the Bank of England’s prediction (in August 2022) that UK inflation would reach 13% in October. What is perhaps as worrying for long-term retention and attraction issues within nursing is that UCAS figures (in August 2022) revealed that 21,300 students were accepted onto nursing courses, a fall of 7% from 2021. The Royal College of Nursing CEO and General Secretary, Pat Cullen, stated that these figures are clearly “headed in the wrong direction.”
Within General Practice, the figures affirm a legacy of continuing shortages; in its September 6, 2022 article, the Nuffield Trust states that despite government promises to increase the number of doctors by 6,000, the number of GPs has fallen by 570 since December 2019.
Within social care, the situation is perhaps even starker. It has been revealed by research from Skills for Care that the number of social care jobs in England in 2020-21 fell (by 3%) for the first time in almost a decade; this equates to 50,000 fewer people in the sector. This is disturbing given that there was £162.5 million of funding provided by the government in 2021, and a national recruitment campaign for the sector.
And when we look into the future for health and social care, we see that the workforce projections make it clear that radical action must be taken now in terms of retention and attraction strategies. The Health and Social Committee Report referred to above, drawing on research submitted to it, estimates that extra 475,000 jobs in health and 490,000 in social care will be needed over the coming decade to meet the demand. In the words of Oonagh Smyth, CEO of Skills for Care, there is a need for a “27% increase in posts in social care by 2035 to continue to maintain the current levels of care.”
BOLD AND MULTI-FACETED ACTION NEEDED
This workforce crisis in terms of shortages merits immediate and bold action. Concurrent with the quantity issue around the need to recruit more staff, there is the quality issue of a workforce facing profound wellness issues, including burnout. This is such a serious matter that we have devoted our workforce and wellness blog to the UK healthcare sector challenges in this arena.
To address the shortfall issues, the government has turned towards the international healthcare workforce market, and it also faces exhortations to publish a credible strategy for workforce planning. On August 8, 2022, the Department of Health announced the launch of a task force to recruit more staff from overseas for both, social care and health ahead of what it anticipated would be a “challenging winter”. It will remain to be seen how effective this will be in a post-Brexit context, given that between January-April 2021, just 1.8% of starters in care came from overseas, compared to 5.2% in 2019 (Skills for Care figures).
The loudest call in terms of the workforce challenges seems to be for a more comprehensive approach from the government. The Kings Fund on August 3 asserted that this is an issue that now cannot be ignored and added that “the workforce crisis and its consequences have been years in the making”.
The Nuffield Trust, responding to the Health and Social Care Select Committee Report of July 2022, has asserted that the failure to plan for workforce needs is placing patients’ safety at risk. Dr. Billy Palmer, a Senior Fellow at the Nuffield Trust, was unequivocal:
“Without a comprehensive, funded, and bold plan for the workforce of the future, this will not be the last Parliamentary Report to raise the alarm about staffing problems in health and social care.”
With a new Prime Minister and new Health Secretary in the office this month (September 2022), it will be interesting to see whether the coming weeks and months will witness such boldness.
