Consultant David Oliver looks at the chronic depletion of NHS investment, pay, training and staffing levels which have led to the current emergency

The Conservative Government is labouring under the delusion that it somehow has no responsibility for the current collapse of health and social care services and the serious risks to patients and staff alike. Yet every challenge services now face has been created or worsened on the Tories’ watch. 

A Number Ten spokesperson told the press that “The NHS is getting the funding it needs” and “there is no crisis in the NHS” on 3 January this year. Three days later, Prime Minister Rishi Sunak called NHS leaders together to discuss solutions to the very crisis that the spokesperson said didn’t exist. NHS data had shown record ambulance handover delays with a number of trusts declaring major incidents. 

In his keynote speech on 4 January, Sunak made the NHS the subject of one of his five key pledges. He told us that “NHS Waiting Lists will fall and people will get the care they need more quickly” – going on to say that “within a few months, we will have eliminated people waiting more than a year and a half for care”.

On the same day, the latest Health and Social Care Secretary, Steve Barclay, claimed that the current winter pressures in urgent care were caused by a surge in Covid-19, Flu and Strep A cases.

Asked what he was doing to ensure the NHS was safe, Barclay said: “We are putting in more funding, we’ve got more staff, over 34,000 more staff working in the NHS, so there are more nurses, more doctors, we have got an extra 7,500 going into social care, we are looking at greater support for domiciliary care…” “There’s £500 million of investment this year going into tackling the pressure in terms of social care,” he added.

Barclay’s predecessor, Therese Coffey had badged herself as the “patient’s champion” and set out a bizarre “ABCD” of priorities for NHS improvement to which she would apply a “laser-like focus”. She lasted 6 weeks. 

Meanwhile, both nurses and paramedics are taking industrial action centred on terms and conditions and the BMA Junior Doctors are about to ballot on strike action. 

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The Current Malaise

The way the Prime Minister and Health Secretary speak, you’d be forgiven for thinking that some other political party had been in power since 2010. But the current meltdown is the culmination of the appalling stewardship of the Conservative Party.  The entire health and social care sector faces a crisis that has been years in the making. Since the 2010 election, health inequalities have widened and the incidence of potentially preventable non-communicable disease has risen, with socioeconomic inequalities both in health and access to healthcare further accelerated by Covid.

Yet the Tory-led government has cut public health and local government grants, scapegoated and disbanded Public Health England in a pathetic attempt to exculpate itself for mishandling the pandemic response and relabelled “inequalities” as “disparities” as if they are the play of chance and nothing to do with failed social policy or amenable to state intervention. 

The Conservatives have also ducked key policy interventions on wider determinants of health around welfare, housing, early years, food, drink, obesity, sugar and support for addiction for ideological reasons and through over-closeness to lobbyists and libertarian think tanks with shady backing. 

Meanwhile, in primary care, there has been no increase in the GP numbers since 2015 and, according to the Royal College of General Practitioners, a fall of 700 in the past two years. However, the number of consultations has risen yearly to record levels. UK GPs routinely deal with twice as many patient contacts daily as counterparts in other high-income nations. GPs are understandably demoralised, burnt out and leaving.

This hasn’t stopped Sunak from promising an additional 50 million GP appointments next year and no waits longer than two weeks – with no detail on how.

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The number of community and learning disability nurses have fallen and we are seriously short of capacity in community health services that might support patients outside hospital or help them to leave sooner. 

The UK already sits near the bottom of the OECD league table for the number of doctors and nurses per 1000 people. We now have around one in 9 nursing vacancies unfilled with around 1 in 12 clinical posts vacant. Social care also has around 165,000 careworker posts unfilled – around 8% of the workforce.

These staffing gaps are partly attributable to worsening terms and conditions. The Nuffield Trust has shown that since 2010, all clinical workforce groups have suffered major real terms pay cuts, and fared far worse than the private sector and compounded by inflation, itself accelerated by the brief disastrous tenure of Liz Truss and Kwasi Kwarteng in Government.  This staffing gaps have been compounded by points-based immigration rules, Brexit and the mood music making the UK seem a hostile environment for overseas-trained staff, in what is a global labour market for scarce and prized skills. 

We have failed to train enough homegrown staff and are doing far too little to retain the staff we have. This won’t be helped by the hardcore stance on industrial action and government attacks on staff groups such as GPs or NHS managers. The serially promised NHS workforce plan has been repeatedly kicked into the long grass. 

Following the 2010 election, local government support grants were cut, as were social care budgets, despite ageing demography and rising demand for care. And despite serial promises to provide solutions to social care funding or provision, we now have fewer people in receipt of what is already heavily rationed care, fewer nursing and residential home places and still no plan. Even the meagre £1.7bn a year for 3 years from the proposed “social care levy” from a National Insurance Increase has been scrapped. 

After losing around half our hospital beds over the past 3 decades, England now has the fewest beds per 1000 people in the OECD nations and hospitals regularly running rammed full. 

Emergency Departments are overcrowded and with increasingly long waits – to the detriment of patients – notably the older and frailer. This is only partly due to a rise in attendances, and more importantly because those patients who require admission have no beds to go to. Deeper wards within the hospitals now face over 10,000 of the 100,000 general and acute beds filled with patients who are medically stable enough to leave hospital but have no step-down services to go to and so are marooned in hospital while they wait. 

Meanwhile, ambulance crews – already demoralised and short-staffed – are struggling to meet response times for any of the four categories of incident. They are also struggling to meet the standard of 15 minutes to hand patients over at the front door of emergency departments because there is no space. While they wait, they are unable to get back out on the road and attend jobs.

At the same time, in planned care, we have around 7 million people on waiting lists for investigations, appointments, procedures and operations and probably millions more missing from lists they have yet to get onto. There is an elective recovery plan set out by NHS England, which Sunak hopes to take credit for, but it will take years, not months to realise. This was partly the result of the Covid pandemic leading to cancellation and postponement. But as a Nuffield Trust report in 2022 pointed out, the NHS has been hit harder than most national systems because of the underlying structural problem


A Decade of Chronic Underfunding

Over the last decade, our Conservative-led governments have put around a fifth less in real terms of funding into healthcare compared to a range of other EU countries. Over the last 7 years, they have presided over the lowest real-terms funding uplift to the NHS in its history. We also spend far less than many comparable nations on capital for equipment, facilities and buildings. 

Before the 2010 election, the NHS was in a good and improving place after 13 years of Labour Government. There were record levels of investment, national improvement programmes and a major focus on access and wait times. Public satisfaction was high and we performed relatively well on international league tables. 

Now every part of the health and social care system is in a dire state and public satisfaction levels are at rock bottom. Nevertheless, surveys show that people still have high levels of trust in doctors and nurses, respect for the NHS as an institution and support for the essential funding and provision model, despite attempts in some quarters to push insurance and market-based approaches. 

In The Guardian Aditya Chakrabortty wrote of the vital skill in modern politics of “differentiating lies from bullshit”

The attempts of Sunak and Barclay to portray themselves as good-faith stewards of the NHS, determined to tackle problems that their party magically had no part in causing, and blaming current problems on viruses and militant workers are examples of both lying and bullshitting.  I hope no sensible voter will buy either.

David Oliver is an experienced NHS Consultant Physician who has looked after Covid wards for many months during the pandemic and has played a variety of national medical leadership and policy roles. He has been a weekly columnist for the British Medical Journal since 2014

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