The NHS has become a ticking time bomb - do we know which wire to cut?

A flurry of staff strikes, never-ending backlogs, hours-long ambulance queues, patients opting for private healthcare; it’s impossible to ignore the issues at the heart of the NHS. Historically, the state of the NHS has been blamed on a growing population; the general public has become frustrated, no longer cared for by the institution that once British people were most proud of. GPs now see 15% more patients than in 2015, delaying first appointments and referrals to secondary care. Once referred, patients wait further. Currently, 10% of the NHS workforce is vacant, limiting how quickly the backlog can be cleared. In January 2023, 58.3% of patients waiting to start treatment did so for up to 18 weeks; a contributing factor will undoubtedly be the 30.8% of patients waiting for a diagnostic test for longer than the 6-week target.

Economists would define the problem as a mismatch between supply and demand. However, the ramifications deriving from this equation are, unsurprisingly, complex.

Where’s the problem? National health or the system?

An ageing population and a growing burden of non-communicable diseases have made chronic disease the main cause of illness and death in high-income countries. The elderly are most likely to require care, and the number of people aged 85 years and older in the UK is predicted to double by 2045. This will create unprecedented pressures on an already stretched system. Moreover, hypertension and obesity are some of the most frequent diagnoses in primary care, despite being preventable. We must also account for long COVID, affecting nearly 2 million people.

A chronically ill and ageing population comes with other challenges; support outside of hospital is one. Social resources (i.e. social and community care) are needed for an effective health system, but have long been underfunded. In 2022, 27% more patients fit for discharge remained in hospital than the year before; in January 2023, over 14,000 beds were occupied by such patients. Low capacity for needs assessment, and a lack of social care beds and care packages contribute to this.

Lack of funding isn’t limited to social care. Revenue collection in the UK occurs through direct taxes, pooled and shared across public services. However, despite the amount of tax the British public pay, the NHS has long been underfunded. Health and social care receive the largest slice of His Majesty’s Government's Budget, but this is no longer sufficient. People are recurring to health insurance and out-of-pocket payments to purchase private services. Could the solution be increased taxation? How would public confidence in HMG affect Britons’ willingness to pay more?

Perhaps the rhetoric could be directed at staff, loved by the general public. Despite modest increases in staff numbers, the workforce vacancy rate is still going up, close to 10% in September 2022. Several factors are at play; health systems require different resources in order to function - physical, knowledge, social and human. Distributional problems, e.g. staff recruitment and retention, are evident, particularly since the shocks caused by Brexit and the COVID-19 pandemic.

The number of EU nationals working for the NHS plateaued following the 2016 referendum, and keeps decreasing. Although hiring rates from Asia have risen, potentially making up for the shortfall, the number of NHS leavers has never been so high. “Relocation” and “work-life balance” are two reasons for leaving the system; a recent report quotes stress, staff shortages and pay as workers’ main exit motivators. Those who stay in the country are moving on to private healthcare, and other non-NHS industries.

Other factors contribute for a diminishing workforce. The 2017 withdrawal of the student bursary for nurses, midwives and allied health professionals has had a lasting impact on the training of new professionals, leading to a 19% lower student intake by 2019. Bursaries were later reinstated for nurses, but other roles did not see the same measure; new professionals pay approximately ￡9,000 in yearly University fees, making a healthcare career just one of many other options, arguably more profitable in the long term.

Physical resources also affect the quantity and quality of services offered. The UK has less than half the average number of beds across the OECD (2.4 vs 5 per 1,000 inhabitants) and three times less than Germany (7.9 beds). What is an already scarce offer is bound to worsen with prolonged stays and an inability to discharge patients. Facilities are no longer fit for purpose, especially against a backdrop of climate change; procedures have been cancelled due to operating theatres overheating during heatwaves, thus prolonging waiting lists. Safety issues and malfunctioning equipment add to the list of concerns, impacting on the number of patients that can be attended to and the speed at which this is done.

Digital transformation delays impact on the system’s efficiency too. Several, non-compatible, software solutions are often implemented across facilities; data does not migrate easily and records may not even be transferred between healthcare providers. Poor investment in updates and infrastructure leaves important security gaps; an example was the 2017 WannaCry ransomware attack, leading to patient records being inaccessible, equipment becoming unusable, thousands of cancelled appointments, and millions of pounds in expenditure.

Have we run out of gas? Or is there fuel left in the tank?

The fragilities in the system are clear, but multi-factorial. The World Health Organisation 2000 health system framework demonstrates that inter-relationships between governance, funding and resources are required for a well-run health system; the “building blocks” framework develops this, separating resources by type. It tells us that blocks are tightly linked, having knock-on effects on each other. Fundamental inputs are all affected: financial resources are stretched, skilled workforce numbers are insufficient, facilities and equipment are in poor shape, among other concerns. High quality governance becomes complicated; a system in worse condition sees more incidents, taking longer to be investigated, and solutions may be challenging to implement with limited resources.

While tackling a higher number of patients may be a near-impossible task, addressing waiting lists via alternative methods may be feasible. The diagnostics sector is being aided by community centres, new professionals trained within shorter-duration programmes, and direct collaboration with private healthcare providers; the latter also supporting with procedural backlogs, aided by the creation of surgical hubs. Apprenticeships have taken off and a fast-tracked visa for health and care workers became applicable to European workers post-Brexit.

The NHS was designed to offer episodic care, focused on treating illness rather than preventing it. Nevertheless, a recent campaign by the UK Government intends at tackling obesity; its long-term results are yet to be seen. Closely related to preventive care, primary care should be patient and community-focused, establishing personal relationships. Regrettably, the number of GPs in the UK keeps decreasing; the House of Commons has issued a report to HMG with clear recommendations on how to address this.

The above measures come with, effectively, a redirection of public monies. It has been found that the general public would support measures to support NHS workers, even if those meant further public expenditure. Compared to 14 of its European counterparts, the UK invested less in healthcare over the last decade. The question of opportunity costs arises; HMG can allocate more funds to the NHS, but which other public bodies would see budget cuts? E.g. reducing the Department of Justice’s budget may lead to more criminals being left out on the streets, and more knife-injury patients needing emergency services. Using a framework for this effect may be beneficial.

Once allocated to the Department of Health and Social Care, funds should be split fairly between social and health services so to be effective; HMG is making available a total of ￡750 million to support discharge-related social care. Within the NHS, how do we prioritise which services need more money, or need it first? The UK is already highly cost-efficient through health technology assessments by the National Institute for Health and Care Excellence. Perhaps investing in more staff, e.g. attracting more by increasing salaries? However, more staff in buildings not fit for purpose will only go so far. Updating facilities would help, but not if insufficiently staffed; replacing equipment is important but if facilities are not well ventilated and insulated, even premium equipment faces limitations. Prioritisation becomes a challenging task, requiring appropriate analyses, task forces and effective management of expectations.

In summary, a resilient health system is aware of its weaknesses and adaptive in the face of challenges. But where do we start? Ongoing pressures require urgent attention from policymakers; growing demand for healthcare, broken care pathways, and under-resourcing are putting the NHS under unprecedented strain. It's imperative that we invest in solutions that will improve capacity, enabling the system to weather future crises.

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