Winter is coming, as it always does, and the NHS creaks and groans. The chancellor will not tomorrow hand over the £1bn it needs to cover the cost of strikes, though NHS debts mount while almost 7.8 million people in England suffer on waiting lists.
But Jeremy Hunt will have an easy riposte, hot ammunition to hurl at the NHS, rehearsing for the upcoming election. A spate of alarming reports all say the same thing: NHS productivity has fallen since the pandemic, with more money and more staff treating fewer hospital patients. So says the authoritative Institute for Fiscal Studies (IFS), parliament’s public accounts committee and the House of Commons library. Here’s what the chancellor can say: in the last five years the NHS has had more money and some 20% more doctors and nurses, yet it treats fewer hospital patients than pre-Covid. Forget asking for more.
But it’s not that simple. Everyone wants value for money, but measuring the productivity of services is notoriously difficult. What gets measured is what’s easy, but often not what’s actually happening or what matters most. If you double the size of school classes, teachers are twice as “productive”. Halve the number of nurses on a ward, and they double their “productivity”. Important note: GPs’ measurable productivity is the NHS exception. There are fewer of them, seeing more patients than before, under intense pressure. Together with other primary care services, they provide 90% of all NHS treatment. Patients in 10,000 new beds in “virtual wards”, intensively treated at home under hospital supervision, don’t appear in these productivity numbers.
These thoughtful reports suggest numerous reasons for falling hospital through-put. There are fewer beds than before. Covid-19 isn’t over, with more than 2,700 beds in England currently occupied by Covid patients. Since the pandemic, infection control has been far more rigorous, taking more space, work and time.
The non-arrival of Boris Johnson’s promised “oven-ready” plan for social care has contributed to a situation in which more than 13,000 hospital beds (out of a total of about 100,000 beds in England) are filled with those who are medically fit for discharge. The president of the Royal College of Emergency Medicine has called hospitals “lobster traps”: easy for the frail to get into, hard to get out of.
Harder to measure is the exhaustion and the change in experience levels of NHS staff. Many who gave their all during Covid burned out and left, the most experienced replaced with beginners. (A new surgeon gets through fewer operations.) Sickness absence is higher. Those once willing to work extra hours – paid or often unpaid – are reluctant: the government’s political attempt to weaponise pay demands caused damaging strikes that always leave a workforce disheartened.
Now add in the shocking cuts to spending on buildings, diagnostic equipment and IT, with trusts ordered to spend their capital budgets on day-to-day care, committing the fiscal sin of mortgaging the future. Forget the phantom 40 new hospitals, most of which are unlikely to be built.
As for money, years of drought have left long-term scars, when NHS funds scarcely rose while patients and population increased. The 2.9% a year average budget increase for the five years to 2024-25 is, says the IFS, well below the NHS’s 3.6% lifetime average – let alone the 7% in the Labour years that bequeathed an NHS in its best state ever.
And then there are the patients. They are older and sicker, and the longer they wait for treatment, the worse their condition. Long Covid has weakened many. All these reports record a greater severity of illness, with patients needing longer hospital stays. Gains in life expectancy are slowing, and for some, it is in reverse. The gap in health outcomes between the north and the south of England is worsening, mirroring the wealth gap. As for quality, the CQC rates 68% of hospitals in London as inadequate or requiring improvement.
Expect the government to turn the blame on to the NHS and its staff, hoping everyone forgets the austerity years, and the catastrophic Andrew Lansley reforms of 2012 that blew the NHS into competing fragments, so chaotic that it’s still undergoing more reform to repair it. Hunt might pause to remember who was in charge of NHS England for six of these drought years of falling performance.
This is Victoria Atkins’ harsh inheritance as she takes over the health and social care department. She arrives full of brio, as an “optimist” who’s “committed to getting round the table” with the doctors: let’s hope she had the wisdom to take the job only on the condition that she could settle with them fast, before winter flu and sickness has ambulance queues lengthening outside hospitals.
All this will be Labour’s legacy too: with waiting lists still rising, expect scant improvement in a year’s time. Wes Streeting promises the £1.6bn tax retrieved from non-doms will buy thousands more mental health staff, district nurses, health visitors and others. From his speech at last week’s NHS providers’ conference, expect a reprise of Harold Wilson’s “white heat of technology” in Labour health plans, with hope from genomics and AI, alongside his emphasis on community and prevention. Summoning the work of Michael Marmot, a professor of epidemiology, on greater equality, he stressed that health is determined more by social conditions than by NHS treatment.
Like all shadow ministers on a throttlingly tight spending leash, he is eager to find improvements and efficiencies that pay for themselves. He has explored anaesthetist Dr Kariem El-Boghdadly’s programme at Guy’s and St Thomas’ NHS foundation trust, whose Saturday high-intensity theatre lists cut through four times more operations just as safely, maximising every minute: the fastest turnaround has been, he tells me, just 30 seconds.
Then there is Leeds Teaching Hospitals trust, where the chief executive, Prof Phil Wood, tells me that this year he has cut 350 beds blocked by patients awaiting social care to 200 by eliminating discharge bottlenecks and releasing people to cheaper, nurse-led convalescence hubs. Working closely with Leeds council, he pays NHS money towards social care: it’s a saving to raise care staff pay, avoiding their flight to the higher-paying Amazon warehouse nearby.
So why can’t everyone be as good as the best? Every new health minister asks that, as if all could surge above average. After disastrously disruptive Tory “reform”, the very word is toxic in the NHS. Streeting hopes Labour, with at least some more money, will arrive with more goodwill after the Tories’ mistreatment of staff, not clapping but assailing them. Raising productivity, however it’s measured, means rolling out efficiencies and innovative ways of working. They exist. It can be done. If not, the NHS will come under increasing attack from all its old enemies.