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Professor Dame Sally Davies, Chief Medical Officer for England between 2010-2019, gave evidence to the COVID Inquiry this week, as part of its first module on ‘pandemic preparedness’.
While much of her evidence focused on the use of scenario planning for pandemic viruses, Dame Sally was also unequivocal in saying that our health and care systems lacked the capacity and resilience to cope with the surge in demand that the pandemic created and that poor population health made our citizens more vulnerable.
She attacked public health cuts and policy since the 2010 General Election, saying “you can’t get a good outcome if you don’t have resilience in the public’s health, resilience in the public health system – it has been disinvested in”.
She went on to say that “on comparator data… we were at the bottom of the table on number of doctors, number of beds, number of ITUs [intensive therapy units], number of ventilators. We needed resilience in social care. That was clearly missing”.
The juxtaposition of her evidence with that of former Prime Minister and Chancellor David Cameron and George Osborne, in which they denied that the Coalition and Conservative Governments’ austerity policies had contributed to the problems Dame Sally described, was stark. But what she said remains unequivocally the case.
In the OECD international tables comparing health systems, England is right near the bottom on hospital beds per 1,000 people – well below the European average. We have also lost around half of our general and acute beds over the past three decades. And we have far fewer ITU beds per 100,000 people than most high income nations (although at pandemic peaks in 2020 and 2021 we miraculously managed to near-double capacity using borrowed or overstretched staff).
Our hospitals run at perilously high bed occupancy every day and we face a daily struggle to create beds to admit patients to. This in turn leads to overcrowding, long waits and handover delays at the front door of emergency departments and, in turn, prevents ambulance crews from getting back out to their next job.
The College of Emergency Medicine estimates that between 300-500 people die each week as a result of the overcrowding and delays. Meanwhile, A&E attendances have increased 17% in the past decade, according to the National Audit Office.
It is increasingly hard to get relatively stable patients back out of hospital who are awaiting step-down community health services – which are well short of required capacity or investment, or social care assessment, funding or provision – whether in their own homes or care homes. The Government has repeatedly promised to fix social care with a lasting solution and has repeatedly failed to do this. The NAO this week reported record levels of “bed blocking”.
Local government support grants, and hence social care budgets, were cut as part of austerity and have never been restored. There are around half a million fewer people in receipt of social care now than there were in 2010, despite the population growing and ageing. Care homes and social care providers are struggling to stay in business.
Not only are we way down the OECD tables for nurses and especially doctors per capita, but our overstretched GPs have seen a fall in numbers of around 2,000 since 2015. Comparisons with a range of other high income nations show them to be dealing with far more daily consultations and to be suffering higher levels of stress and burnout. Yet GP appointment numbers have increased by 18% since 2018-19 alone.
We have a workforce crisis in the NHS with a high and growing number of unfilled posts, especially in nursing. The recruitment and retention crisis in social care is even worse, and has been compounded, by points-based immigration rules which discriminated against poorly paid workers and by competition with other sectors now short of labour.
The long-promised NHS England workforce plan has still to appear, partly due to Treasury concerns over affordability – which will in turn affect training places and salaries. We have seen industrial disputes involving doctors, paramedics, physiotherapists and nurses as NHS real terms pay has fallen well behind the private sector since 2008 and is now compounded by the cost of living crisis.
Highly trained NHS clinical staff have exportable skills and qualifications which they can and will take elsewhere. The annual staff satisfaction survey has shown lower morale scores than at any times since data were reported.
The NHS has repeatedly failed to invest sufficiently in capital expenditure on now-crumbling buildings or on modernising equipment or digitalising systems with money repeatedly raided for revenue to run services.
Even before the pandemic hit the NHS, these trends of worsening access, longer waits, short-staffing, worsening staff morale, and growing public dissatisfaction (in the 2022 British Social Attitudes Survey, now at its lowest point since 1997) were growing.
A 2022 Nuffield Trust Comparison of several developed nations showed that, although all countries were impacted by the pandemic in terms of backlogs of planned care and longer waits, the UK had been hit the hardest because we already had so little headroom.
Meanwhile, as Sir Michael Marmot’s 2020 report showed, health inequalities had already been growing before the pandemic, as had the incidence of preventable diseases. The Health Foundation last year updated these findings to show that the pandemic had worsened these health inequalities and increases in both absolute and healthy life expectancy have now stalled and begun to reverse.
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Public health grants have suffered sustained cuts and various governments have refused to implement effective public policy on the wider determinants of ill-health such as housing, food, obesity, smoking, drinking and support for addiction and mental health. Part of this refusal has been for ideological reasons and the influence of lobbyists.
During the New Labour years, the NHS in England received an annual real terms funding uplift of around 6% (the highest in its history) and, following the 2010 General Election, this dropped to seven years of only 1.4% (the lowest) despite the inevitable cost increases generated by population demographics and rising costs of treatment.
In 2010, after this funding increase and the impact of Labour’s NHS Plan, the service, while not perfect, scored highly on public and staff satisfaction and on several aspects in international comparisons.
Austerity, combined with a series of poor policy decisions (notably the 2012 Health and Social Care Act and social care cuts) and ducked policy (for example, around terms and conditions, social care reform or public health interventions) left us in a far weaker position by the time I was looking after my first Coronavirus patient in March 2020.
Cameron and Osborne’s denial of these realities is as jaw-dropping as Boris Johnson’s lies around ‘Partygate’ – but ultimately far more serious.
Dame Sally Davies should not be let off scot-free when she was herself the CMO and could have done more to highlight some of these issues both publicly and privately. She also failed to tell us why she did not push harder for pandemic planning exercises based on SARS or MERS viruses when she was told (by whom?) that “it won’t come here”.
But she showed the kind of integrity and honesty and insight and sympathy for the pandemic’s victims that these two former politicians characteristically failed to.
David Oliver has been an NHS acute hospital doctor for 34 years, looked after a Coronavirus ward throughout the pandemic waves, and has held a variety of medical leadership and policy roles. He is a regular columnist for the British Medical Journal