It’s like a scene from an old war movie. The National Health Service is a Royal Navy ship crashing through a stormy sea being buffeted by wave after wave of surging demand. Fuel is running low. The captain calls for more power. The needle on the engine room pressure dial goes above 100 per cent, and becomes stuck deep in the red zone. After ten minutes of running at absolute maximum power the engines falter and the ship shudders. Nervous glances cross the bridge. How much longer can the ship stay in the red zone? Can it stay afloat? When will it founder?
Excuse the dramatic license, but that’s how it feels in the health service at the moment – we’re trying to run the NHS permanently above its sustainable limits, well into the red zone.
Take NHS funding. We are in the middle of the longest and deepest financial squeeze in NHS history. Costs and demand are growing by five per cent a year, but we are in the midst of a twelve year stretch where funding, on current plans, will rise by less than one per cent a year on average.
Although NHS trust finances have started to stabilise, there is still an underlying deficit of at least £3.5bn. We are only balancing the books by robbing capital budgets, selling off land and making one-off, nonrecurrent accounting adjustments or savings. The consequences are increasingly obvious; for example, the safety-critical NHS maintenance backlog has more than doubled in just two years from £458m to a whopping £947m. As the National Audit Office has pointed out, the health service at a local level remains under considerable financial pressure and the NHS still has a long way to go before we can regard it as being once again on a sustainable footing.
The workforce pressure dial is firmly in the red too. We have widespread staff shortages. There are growing recruitment and retention problems due to Brexit and ongoing NHS pay restraint. Many staff argue they can’t provide the safe, high-quality care that patients deserve, despite routinely working longer than recommended or paid hours.
I was particularly struck by a conversation I recently had with a nurse who, after building her experience and expertise for 12 years, had decided to leave the profession because she had woken up too many times at three in the morning worrying about whether she had been able to do her job safely. That is what trying to run the NHS permanently in the red zone looks like from a staff point of view.
It is the same situation with NHS performance. We have now reached a point where the health service is no longer able to deliver all that is being asked of it. Mental health bed occupancy rates regularly reach 100 per cent. District nurses are run ragged, trying to cover an impossibly large number of patients. Despite best efforts, for the first time ever last year, all four key NHS hospital performance targets were missed. Waiting lists for routine surgery are the longest for a decade. And only a handful of trusts are consistently meeting the four hour target in A&E.
Last winter provided graphic evidence of what running in the red zone looks like for patients. Far too many mental health and community services stretched to capacity. Far too many patients stranded in ambulances queueing outside overcrowded A&E departments. Far too many twelve-hour trolley waits in busy corridors. Too often, patient safety is being put at risk.
The trust leaders we represent – the people who are responsible for providing frontline care to a million people every 36 hours – are clear what they need to offer the safe, high-quality care we all want the NHS to provide.
Firstly, honesty and realism about what can be delivered with the funding available. Trusts want to deliver the performance standards set out in the NHS Constitution, but they can only do this if they are properly funded to meet those targets. Their leaders are not magicians; they cannot deliver the impossible. So the November Budget needs to set a clear plan for the rest of this Parliament which matches NHS delivery expectations to the money available.
We must also, as a matter of urgency, come up with a clear strategy to address the workforce challenges that trust leaders now say are their biggest problem. That includes a plan to end pay restraint, and much-needed reassurance and clarity for the current and potential future NHS workforce on what happens after Brexit. Above all we need urgent steps to fill gaps in the current workforce and an affordable long-term strategy that sustainably matches workforce supply to likely future demand.
Finally, we should support the NHS to deliver the transformation in care that is required to meet the growing and changing needs of our society. That means putting greater emphasis on preventing ill health and ensuring wellbeing. It also means delivering much more care closer to home so hospitals are used only for those who require acute care. We need a better integrated health and care system where different elements – community, mental health, ambulance and hospital services, GPs and social care – come together to serve the needs of the population.
It is painfully clear that the NHS is now running in the red zone. We need national NHS leaders to acknowledge this is simply unsustainable. As the health service nears its 70th birthday, now is an opportune moment to make the big decisions which are urgently required to reach calmer waters, and bring that pressure dial round to “safe”.