While we are all relieved to be seeing the tail end of the pandemic, for the NHS the aftermath hasn’t meant the end of the trauma. Exhausted staff want to heave a sigh of relief and get back to normal. But “normal” is not on the table, unfortunately. They face a backlog that is unprecedented in the history of the NHS – with a figure of 5.6 million on the waiting list actually being closer to ten million when you account for those who have not yet presented, and 6,000 people waiting more than two years for their treatment.
Rishi Sunak’s £12bn “health and care premium” shows welcome pragmatism. We now have a transparent mechanism for the big increases in health and care spending that will be needed over the decades ahead. At every election we can now have a more sensible debate about what funding the NHS and care system will need over the coming parliament, separate to the more general issues around public spending.
If there is one thing I wish I had known at the start of my time as health secretary, it is that money alone is not enough to solve these kinds of issues. You can give £8bn a year more to the NHS, but if you do not have the equivalent in additional doctors and nurses, the money will tend to bid up the salaries of locum doctors and agency nurses rather than fund more treatments. Even if the money is attached to targets, the effect can often be to suck clinicians from one part of the NHS to another – more money for elective care meaning fewer cancer doctors or GPs, for example.
We have a shortage of doctors in nearly every single specialty. The Health Foundation estimates it will take 4,000 more doctors and 18,000 more nurses to clear the backlog, but so far there appears to be no plan to find them. Immigration is no longer an option; other countries have their own backlogs. There is a global shortage of 2.1 million doctors according to the World Health Organization.
This NHS workforce crisis should exercise all parts of the political spectrum. It is key to tackling burnout, improving working conditions, getting through the backlog and making sure the additional funding actually delivers what it is meant to.
Some people reading this will say “you were the longest-serving health secretary, so why didn’t you address these issues”. I do not pretend to have got everything right and my failure to deliver the target I set for 5,000 more GPs was as disappointing for me as for the profession. But I did establish five new medical schools and increase doctor, midwife and nurse training places by 25 per cent, the biggest-ever single increase. However, because it takes seven years to train a doctor, the impact of those changes is yet to be felt on the frontline – which is why I have come to the view after leaving office that we need a new system that operates outside the Westminster parliamentary cycle.
In the short term, we should throw the kitchen sink at getting more doctors and nurses into the system. As a first step, we should relax all immigration restrictions for qualified clinicians, as well as offer generous incentives to overseas medics. The NHS and care system would simply fall over without clinical staff from overseas and we should welcome them with open arms. However, we should recognise there is an element of moral hazard in this approach: such recruits often come from developing countries where their services are required even more. So, depending on immigration from poorer countries should never be a long-term strategy.
We can also do much more to retain staff, starting with fixing the pension tax taper that is causing consultants to retire early or limit their hours. We should also devise a generous incentive scheme to persuade some of the retired clinicians who stepped up to help during the pandemic to extend their service again.
But this is surely the moment for some more profound changes to set the NHS up for the longer term.
Too often the number of doctors and nurses we train is the very last thing discussed in spending review discussions between a chancellor and a health secretary. Given any decision will not impact the NHS for around eight years it is rarely a priority for either. Even worse, because it does not count as “frontline” NHS spending it is not ring-fenced in the core NHS budget, but in a budget held separately by the Department of Health. Often it gets cut as part of a deal to help fund increases in the more politically sensitive NHS England budget.
The Office for Budget Responsibility has proved to be an important reform that keeps chancellors honest with their budgets. We need similar objectivity when it comes to doctor and nurse training places. Health Education England should be given the statutory duty to produce independent workforce forecasts for the needs of the NHS and care systems for the next ten, 15 and 20 years – with estimates as to the numbers we should be training now. It would be up to ministers to decide whether to fund the need, but at least there would be transparency on whether we are or are not training enough doctors and nurses. The royal colleges, NHS Providers and health think tanks have put down an amendment to the Health and Care Bill to deliver this, which I strongly support.
We should also consider further structural changes such as removing the caps on places at our often world-class medical schools to allow them to expand into global centres of medical training. We should look at the contents of the curriculum and the length of courses, something that has not been reviewed for many years. Now is also the time to reconsider some of the traditional demarcations between professions. Much hangs on the ability of ministers to take immediate action to fix the workforce crisis. But frontline staff know that there is no immediate fix for many of the shortages they see every day. What they want is the comfort of knowing there is a plan in place to make sure the current pressures will not be permanent. After what they have done for us all in the past 18 months, it is the least we can give them.
Jeremy Hunt is the former health secretary and the current chair of the health and social care select committee