Intended for healthcare professionals

Opinion

The steady crisis across the NHS

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1566 (Published 24 June 2022) Cite this as: BMJ 2022;377:o1566
  1. Danielle Jefferies, analyst, policy team
  1. The King’s Fund

Over the course of the pandemic, NHS performance against national waiting time targets has repeatedly hit new lows. More recently NHS performance has plateaued, however it’s plateaued at a level that is putting patients at risk.

Performance has flatlined at new depths because of fundamental problems within the NHS. These underlying problems that existed pre-pandemic, notably the workforce crisis, have caused performance to stagnate. The workforce is the beating heart of the NHS, but high vacancy rates mean it hasn’t got the capacity to keep pace with demand. And each delay caused by demand outstripping workforce capacity, is having a knock-on effect somewhere else.

The state of the NHS cannot be measured just by its planned and emergency care performance, but these metrics are the most widely available and give an indication of the care available to patients each month. Walking through the hospital it’s clear that the NHS is in a steady crisis.

At the front end, the ambulance staff are struggling to maintain standards. Response times for emergency ambulances have sat uncomfortably at around 40 minutes for nearly a year.1 In fact, the 18 minute safety standard for this category of patients hasn’t been met since the early months of the pandemic, in July 2020.

There are some signs of hope, for example, last month waiting times for patients needing an emergency ambulance were almost 12 minutes faster than the previous month. But they were still waiting on average 20 minutes longer than they should have been.

These long response times are partly being caused by the relentless pressure in emergency departments, as ambulances are getting stuck at hospitals waiting to handover patients.

But staff in A&E departments are also stuck in a dark place. The national standard for 12 hour waits in A&E is 0 patients. But in May more than 19 000 patients waited over 12 hours in A&E for a bed.2 Again, there is a glimmer of hope as 12 hour waits fell slightly last month. But 12 hour waits consistently in the thousands is a symptom that something is going fundamentally wrong with patient flow.

Travel further into the hospital and it becomes clear that this is not just an issue within the A&E department. It appears that inpatient staff are struggling to discharge medically fit patients from their wards. The number of “delayed discharge” patients jumped up after the January wave of Omicron and has stayed consistently high ever since—an average of 12 000 patients on any given day in hospitals across England.3 There’s no set standard for the number of delayed discharges, but every extra patient affects flow through the hospital, as the beds are needed for acutely unwell patients in A&E. A combination of high vacancy rates in both health and social care is limiting the system’s ability to discharge patients into the community.

The only silver lining is that the number of these medically fit patients waiting in hospitals has stabilised. It could have easily escalated when the additional funding to support discharges during the pandemic was withdrawn at the end of March.4

And then there are the patients that the workforce simply doesn’t have the capacity to treat right now—the people on the elective waiting list. Some hypothesised that there would be a sudden increase in the elective waiting list post-pandemic, but instead the rate of increase has been steady. But either way, the list has now reached 6.5 million people in England, and pressure across the system makes it difficult to see where the capacity to treat these patients will come from.

Two year waits for elective treatment did fall by nearly a quarter last month, bringing hospitals closer to NHS England’s target of eliminating these by this July.5 However, if waiting times are not brought under control, two year waits will eventually start ticking up again.

Stabilisation of performance is still better than further deterioration and we should be positive about the recent signs of progress. At the same time, we need to acknowledge the potential harm to patients from ongoing delays.

Capacity is tight across the health and social care system and there’s no flexibility for delays at any stage. The lack of resilience in the system is now stifling post pandemic recovery.

The consequence of ignoring underlying issues, like chronic workforce shortages, is a healthcare system consistently in crisis. The only way out of this situation is to increase capacity across the system—particularly staffing capacity. The NHS has shown in the past that it can deliver rapid improvements to patient care when it has enough staff to tackle these challenges. If we want to break the cycle of consistently poor performance, the government needs a fully funded workforce plan for the whole health and social care system.

Footnotes

  • Competing interests: none declared.

  • Provenance and peer review: commissioned, not peer reviewed.

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