Intended for healthcare professionals


The NHS crisis has been years in the making

BMJ 2023; 380 doi: (Published 13 January 2023) Cite this as: BMJ 2023;380:p96
  1. Jonathon Holmes, , NHS Providers policy adviser

Fears this winter would be one of the toughest for the NHS are fast becoming reality, writes Jonathon Holmes

Trust leaders tell us the NHS is in crisis. We are seeing a whole system under sustained and mounting pressure as demand for services continues to outstrip capacity. Urgent and emergency care services are most visibly bearing the brunt of this pressure. Meanwhile, waiting lists for planned care have increased significantly, and the physical and mental health of the population appears to have deteriorated as health inequalities widen.12

This crisis was not created by the covid-19 pandemic. The virus’s direct impact on our health, and some measures to contain its spread, have exacerbated these problems, but to attribute the pressures in urgent and emergency care today to covid-19 alone is erroneous.

Since 2010, we have seen a decade of squeezed funding resulting in a lack of investment in maintaining buildings, a declining number of beds, insufficient diagnostic equipment, failure to grow the NHS’s workforce in line with increasing service demand, and a failure to invest in community health, mental health, and primary care. Diminishing budgets in social care and the stalling of reform have kept delayed discharges stubbornly high. This means that people too often remain stuck in hospital when they are medically fit for discharge because of a lack of capacity in social care and other community services. As the NHS continues to plough through record demand and manage the ongoing effects of the pandemic, trust leaders are stepping up plans to recover core services, reduce waiting times, and deliver the services the public expects.

The recent NHS operational planning guidance set out challenging but realistic expectations.1 For example, recent performance figures have seen average ambulance response times of more than one hour for serious and life threatening conditions such as strokes or heart attacks, and the current target is 18 minutes (and expected to improve to 30 minutes in 2023/24). The remaining winter months and beyond will see NHS organisations continue to face exceedingly high demand. NHS Providers’ recent survey of trust leaders found that 86% of respondents were “very worried” about meeting demand in 2023.2

The current crisis won’t be resolved imminently, but trust leaders are taking immediate changes to manage the pressures more effectively. Many trusts have increased the number of initiatives to improve staff wellbeing, including offering financial support to help with the cost-of-living crisis where possible. While vacancy rates and staff resilience can only be sustainably improved through the national lever of a fully costed and funded workforce plan, local measures can help reduce stress and improve retention in the short term. Other trusts have undertaken collaborative working arrangements to share intelligence, data, and—most importantly—resources to meet demand across larger geographic areas in “place based partnerships.”

Local examples highlight effective practice and show how providers can continue to deliver in the most challenging contexts, but unavoidable and systemic factors mean capacity can only stretch so far. The current pressures on the NHS are born of a fundamental mismatch between supply and demand across the entire health and care system. Resolving this is key to putting the NHS on a sustainable footing and ensuring that health and care services operate successfully. This is a long term task.

To their credit, the government and NHS England have attempted to manage demand by introducing clinically led system control centres and by working with trusts to help reduce ambulance handover delays. Even so, managing demand better will not be enough. The focus must be on reducing demand by improving prevention, and on increasing the supply of beds and staff.

Improving population health and will require a cross-government approach. Tackling the broad array of social and economic determinants of poor health is essential, as is investing in preventive healthcare services, such as weight management or screening for cardiovascular disease and cancer. Increasing bed supply in hospitals and supporting trusts offering virtual wards should also be a priority. The number of hospital beds in the UK has been falling since the late 1980s and is now one of the lowest, per capita, compared with the other OECD countries.

The crisis in the NHS today is historic. It was many years in the making, so its resolution cannot be found overnight but instead through sustainable, long term investment from the government, a clearer focus on supporting the workforce, innovation, and commitment from frontline staff and leaders.


  • Competing interests: none declared.

  • Provenance and peer review: commissioned; not externally peer reviewed.