Is the NHS overwhelmed?

Finding the right words to describe the pressures facing healthcare services in England right now is difficult. They are certainly not normal: at least 24 NHS trusts declared a “critical incident” in the first week of January,1 which means they may not be able to provide urgent or safe services.2 In November 2021, 10 000 patients waited over 12 hours in emergency departments after a decision to admit to hospital—five times more than in 2020 and nine times more than in 2019.3 Since then, covid-19 cases have spiked,4 and staff absences in hospital are up by around 40%.5

But is the NHS overwhelmed? The British Medical Association says so: “the facts, figures, and the living reality for thousands of patients and NHS staff daily demonstrate undoubtedly that the NHS is currently already overwhelmed.”6 But the prime minister is not so sure: “different places, at different moments, will feel at least temporarily overwhelmed,” he said last week.6 Just not enough—yet—to warrant further measures to control covid-19 cases.

Protecting the NHS from being overwhelmed has been a government priority throughout the pandemic.789 This has often been interpreted as the number of people in hospital and the capacity, such as numbers of beds, available to treat them.10 But there is no clear definition of an overwhelmed healthcare system, despite the risk of it happening looming large in the political psyche.

One version might be when a healthcare system cannot provide care to people who need it. Reports from Italy in March 2020 of patients lying in hospital corridors and shortages of ventilators offered a distressing example of what this looks like.11 But less extreme forms are pervasive and harmful: many countries postponed planned services during the pandemic and some reduced emergency care.121314 In the NHS, covid-19 led to a massive disruption of care and a huge backlog of unmet need, including six million people now waiting for routine hospital treatment.15 Rationing in the NHS is nothing new16 and has helped the system deal with covid-19 pressures. But when does rationing reflect not coping?

Another version of “overwhelmed” might be when quality of care falls below an acceptable threshold. Staff shortages in the NHS stood at 100 000 before covid-19.17 Now more than 80 000 hospital staff are also off sick or self-isolating—around half because of covid-19.5 Patient safety is at risk.1819 The army has been called in to help London hospitals.20 And people are being asked to find lifts to emergency departments because ambulances are taking so long to arrive.21

What measures can tell us when things have gone from bad to overwhelmed? In the NHS constitution, government sets out various performance standards for NHS care and rights for patients, such as the right to start non-urgent consultant-led treatment within 18 weeks from referral.22 In October 2021, more than two million people had waited longer than 18 weeks for routine hospital treatment—and more than 300 000 people had waited more than a year.3 Access to care fell furthest in the most deprived areas during the pandemic.23 But poor performance predated covid-19: the NHS has missed key national targets on cancer, planned, and emergency care for several years.3 Has the NHS been overwhelmed this whole time?

Perhaps being overwhelmed is more of a feeling. After nearly two years of the pandemic, NHS staff are exhausted and almost half report illness from work related stress.24 Some have experienced severe moral and psychological distress.2526 Recent public polling suggests that one in four people are not confident in the NHS’s ability to provide the care they need.27

The Oxford English Dictionary offers various definitions of overwhelmed, including “sudden ruin or destruction.” But looking for a single moment when the NHS goes up in smoke misses the point. Millions of patients and staff are already feeling the negative effects of a healthcare system struggling to cope with the unbearable demands placed on it. This will not be a short term phenomenon: government has provided insufficient funding to clear the backlog of unmet care28 and the NHS has no long term plan to deal with staff shortages.

Looking for a single definition also misses the point. Different healthcare systems have different starting points, values, and expectations—and these change over time. Going into the pandemic, the UK had fewer doctors and hospital beds per capita than most comparable countries. Germany, meanwhile, had high levels of both.1329 Yet both countries have been high spenders on their health system response to covid-19 compared with other European countries.13 These and other factors, like political leadership and public health measures,30 have affected the ability of healthcare systems to cope with covid-19. Longstanding underfunding and neglect of social care in England has also had an effect.31

The prime minister has suggested England can “ride out” the latest wave of covid-19 infections without introducing further covid-19 measures.6 He faces pressure from his own MPs to avoid more restrictions32 and relied on Labour votes to introduce the relatively modest policy measures already in place. This is ultimately a political gamble—and government must be honest about the consequences for the NHS and the public it serves.