Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Politicians’ abject failure to tackle the existential crisis in the NHS

BMJ 2022; 378 doi: (Published 03 August 2022) Cite this as: BMJ 2022;378:o1904
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

After the ousting of Boris Johnson as prime minister and the loss or replacement of many government ministers—including those at the Department of Health and Social Care—we’re now faced with the ongoing instability of a Conservative Party leadership contest, the further ministerial churn that will follow, and a potential general election within 18 months or so.

In the meantime, NHS and social care systems in England are facing a fight for viability right here, right now. But I see no sense of urgency, clarity, or purpose—or even acknowledgment of the scale of the problem—among the leadership contenders or the wider party. Nor do any of their soundbites or policies grasp the need for radical, immediate action. The lack of focus on the NHS and the absence of meaningful discussion on social care have been notable in the leadership contest.

Maybe this is no surprise, when government policy over the past 12 years has contributed so much to the current problems and when sections of the Conservative Party are ideologically opposed to the very NHS model, though they may be reluctant to say so in public. Even opposition leaders are avoiding strong, urgent policy suggestions this far out from an election manifesto. But in early July every NHS ambulance trust in England was forced to declare a major emergency, on what was described as their “worst night ever.”1

At least the cross party Health and Social Care Select Committee has uncompromisingly set out the scale of the challenges in its most recent report.2 These include the huge number of unfilled clinical vacancies in the NHS (which already has fewer doctors and nurses per 1000 than most high income countries), the workforce crisis in social care, and the impact of covid, burnout, and overwork on staff morale and retention.

We also have a record number of people—over six million and counting—on waiting lists for elective appointments, tests, and procedures; a crisis of overcrowding, long waits,3 hospital exit blocks, and ambulance response and handover times in acute care4; worsening problems with workload and access in primary care; a funding and workforce crisis in social care5; and a major shortfall in capital expenditure on maintenance, equipment, and IT.6

A good starting point

Acknowledging the scale of the problem openly and honestly, and illustrating it with data, would be a very good starting point. At a recent round table hosted by the Health Service Journal, a whole range of current NHS chief executives (and not just those so senior or close to retirement that they were fireproof) spoke out in a way I’d never witnessed. They said in no uncertain terms that they were “presiding over a failing NHS.”7 The British Social Attitudes Survey 20218 showed that, despite high notional support for the NHS and trust in doctors and nurses, public satisfaction with the NHS was at a 25 year low, with respondents clearly citing short staffing and poor access as the biggest problems. More people than ever are resorting to using their own money to access private elective care.9

Of course, we need a broader policy discussion about how to redesign and improve services in the long term, but the first thing is to take immediate and radical action to stop services from collapsing this year. We need far better terms for frontline workers—not just pay, but pension rules and conditions of employment—to improve retention and morale before we haemorrhage even more staff. July’s proposals by pay review bodies10 won’t begin to cut it.

We need to act now to ensure that immigration rules allow and encourage more overseas staff to come to the UK or stay here, and we must make them feel welcome. This includes lower paid staff groups and social care workers, whose workforce gaps dwarf even those in the NHS.11 And we must pump money into social care, by any means—the kinds of sums needed to restore coverage and access to the levels of a decade ago. The desultory £1.8bn a year from national insurance rises, promised in the government’s “social care plan” and “levy” last year, won’t even touch the sides, as the Health Foundation’s economic modelling has clearly shown.12 And Liz Truss, the likely winner of the Tory leadership contest, wants to reverse even that.13

Perhaps most importantly, politicians and NHS national leaders need to level with the public about what we can realistically expect in the current climate and how bad things will continue to be for the foreseeable future, while engaging voters in facing up to the need for hard choices and trade-offs. I can’t see it happening, partly because the party of government for the past 12 years has presided over the decline of health and social care services through its own poor decisions. But at some point the conversation must happen—instead of soundbites, over-promising, vague “jam tomorrow” ambitions, and half baked or discredited policy ideas.