There is still time to save the NHS, but time is running outBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2587 (Published 22 October 2021) Cite this as: BMJ 2021;375:n2587
The NHS is falling over. Not everywhere, but in some places and in some services the signs of extreme stress are manifest. These signs are the result of the irresistible force of rising demand for care meeting the immovable object of constrained capacity.
Something has to give. For an increasing number of patients, timely access to acceptable standards of care is no longer possible. For staff the challenge is to deal with unprecedented workloads when vacancy and sickness levels among their colleagues remain high. The psychological safety of staff is at risk with consequences for themselves and the patients they treat.
Evidence of stress can be found in many places. University Hospitals Birmingham NHS Foundation Trust was recently downgraded by the Care Quality Commission with standards of care in emergency departments a particular concern. At Brighton and Sussex University Hospitals NHS Trust surgeons and anaesthetists have expressed concerns about delays in the treatment of time-critical emergency and trauma cases. Nottingham University Hospitals NHS Trust has restricted the provision of chemotherapy services because of staff shortages and has been downgraded by the Care Quality Commission, with emergency services and maternity services both being a concern.
General practices are also in the firing line. Despite carrying out record numbers of appointments, practices have been criticised for delays in seeing patients and not offering face to face appointments to all those requesting them. In response NHS England has published a plan for improving access and supporting practices, but attacks on general practices in the media and by ministers has accentuated the pressures that practices are under, even with the additional funding that has been announced.
The ambulance service is a signature example of the state of the NHS today. There are growing concerns at the length of time ambulances are required to wait to handover patients at hospitals because of the volumes of patients attending emergency departments. Lengthening handover times put patients at risk and delay the ambulance service responding to other calls because their teams cannot be released to do so. The Royal College of Emergency Medicine and the College of Paramedics have warned that handover delays threaten patient safety.
Social care faces challenges that are equally significant and growing. Staff shortages resulting from Brexit and competition from the retail and hospitality industries have accentuated these challenges. Some care homes are having to cancel their registrations to provide nursing care leaving residents to look for places in areas that are at or close to capacity. The Care Quality Commission has rightly highlighted adult social care as a major concern in its new state of health and social care report.1
One of the consequences of what is happening in social care is that hospitals are experiencing increasing difficulties in discharging patients who are medically optimised. This puts even more pressure on hospital beds and contributes to the growth of corridor care in emergency departments. The interdependency of health and social care underlines the need to find sustainable solutions for both encompassing funding and staffing.
Where does covid fit into this picture? Around 8,000 patients with covid are currently in acute hospitals and around 800 are in intensive care.2 While not trivial, these numbers are much lower than at the peak in January 2021, but they are nevertheless contributing to stress across the NHS.
The reason is simple. Core capacity, such as hospital beds and intensive care facilities, has been reduced over many years leaving no buffer to deal with surges in demand. Relatively small changes in demand therefore have significant impacts of the kind that are now appearing.
To claim that the NHS is coping—as Sajid Javid the secretary of state for health and social care did earlier this week—is stretching credulity to its limits. My experience as a non-executive director of an NHS Foundation Trust and chair of an Integrated Care System is that the NHS and its partners in social care are working tirelessly to respond to the needs of patients and service users, but staff face a Sisyphean task.
Tackling the backlogs that have built up during the pandemic will take time added to which are the challenges of the coming winter and uncertainty over covid. The solutions lie in continuing to protect the NHS to ensure that all patients receive timely care of a high standard. Protecting the NHS means, above all, taking care of staff, valuing their work, retaining staff by offering flexible contracts, and attracting back staff who wish to contribute.
It is hard to exaggerate the negative impact of the pandemic on the health and wellbeing of staff. Continuing service pressures have amplified this impact as illustrated in the Care Quality Commission’s reports, discussed earlier.1 An example was the report on Birmingham which raised concerns about staff feeling under pressure to provide care in a way they felt was unsafe in response to workloads in emergency departments, highlighting the challenge of psychological safety in the workplace.
The government now needs to invest resources to build the resilience in health and social care that was lacking during the pandemic. Core capacity including staff, beds, and equipment must be expanded and paid for by an earmarked fund separate from the budget needed for existing services to ensure it is used for capacity building. The highest priority is a fully funded and credible plan to train and develop the workforce of the future without whom there will be no NHS and social care.
There is still time to save the NHS but time is running out. Ministers need to get out more and see for themselves the realities on the ground. They might then form a more realistic assessment of what is happening and what needs to be done.
Competing interests: Chris Ham is chair of the Coventry and Warwickshire Integrated Care System, Co-Chair of the NHS Assembly and non-executive director of the Royal Free London Hospitals NHS Foundation Trust. He writes here in a personal capacity.
Provenance and peer review: Not commissioned, not peer reviewed