In a TV studio in Stoke-on-Trent last month, Liz Truss and Rishi Sunak traded blows about everything from the credit card economy to Channel migrants and accessories chain Claire’s. The list of problems the couple faced was dizzyingly long.
There was one glaring omission, however. In the hour-long debate, there was not a single mention of the NHS, despite being embroiled in its biggest crisis yet. The NHS now shares the same traits as many of those who rely on it to keep them alive and well: it is large, has multiple co-morbidities and needs urgent emergency care. The summer has left him on his knees. Worse is expected this winter.
“The new prime minister will inherit an NHS in the worst state in living memory,” says Matthew Taylor, chief executive of the NHS Confederation, which represents the health system in England, Wales and Northern Ireland. “There is no escaping the fact that the NHS is in a state of crisis.”
The facts, he says, speak for themselves. “There are 105,000 vacancies. A&Es are full of people. Around one in seven hospital beds are occupied by patients who cannot be discharged. Some patients have had to wait more than 40 hours for an ambulance. Care is put at risk by abandoned buildings due to underinvestment. And then there are the waiting lists, which run into the millions across elective care, mental health and community care.”
Jeremy Hunt, the chairman of the health and social care committee, is equally worried. “The new Prime Minister will inherit an NHS that is facing the worst crisis in its history,” he warns. “Health services, ambulances, general practice and social care are at serious risk across the country.”
The overarching problem for the new Downing Street incumbent is that, while in previous years problems in the NHS were focused on specific areas, today the whole house is on fire.
“The NHS has never been more challenged than it is now,” says Alastair McLellan, editor of the Health Service Journal. “There is no area of NHS provision that is not really struggling… There is literally nowhere where it is not bad, and in some cases very bad.”
Ambulances outside a London hospital. A record 29,317 people had to wait more than 12 hours in English A&E departments in July. Photograph: Andy Rain/EPA
In the short term, says Robert Ede, head of health and social care at the Policy Exchange think tank, the key task will be to prioritize. “Almost all the lights on the dashboard are blinking. The singular priority for this winter should be ensuring that patients can access basic services.”
One light that flickered all summer was urgent and emergency care. A record 29,317 people had to wait more than 12 hours in English A&E departments in July from the decision to admit to being admitted. This was up 33% from 22,034 the previous month and is the highest for any month on record going back to August 2010.
“Patients are facing extremely long waiting times,” says Dr Adrian Boyle, vice-president of the Royal College of Emergency Medicine, who says many are in a critical condition or have serious injuries. “We know that long patient wait times can cause harm or worsen conditions or injuries. The sheer number of patients waiting for care is alarming.”
Ambulances in England took an average of 59 minutes and seven seconds last month to respond to emergency calls such as strokes, up from 51 minutes and 38 seconds in June, well above the target of 18 minutes “If you call an ambulance in the Southwest … there’s a reasonable chance you’ll die before it shows up,” says McLellan. “As bad as the NHS has been in the past, this has not tended to be the case.”
Richard Murray, the executive director of the King’s Fund think tank, agrees. “While the waiting list that has crossed the 6.7 million mark may sound exciting enough, the depth of the challenge in emergency care, seen in ambulance and A&E waiting times , is worse. The NHS’s recovery plans have been hampered by repeated waves of the Omicron variant and, more fundamentally, by a deep and long-standing labor shortage.”
General practice has been particularly affected by the lack of recruitment and retention of sufficient staff. “Many patients say it is difficult to get a GP appointment even though primary care colleagues are working smoothly,” NHS England chief executive Amanda Pritchard admitted in a note to staff this month.
In 2015, the government pledged to recruit 5,000 more GPs over five years, but numbers have fallen rather than increased. In 2019, the government promised 6,000 more GPs by 2024, but progress has been glacially slow.
“The new Prime Minister must make general practice a top priority if he is serious about ensuring the NHS remains sustainable to deliver care to patients now and into the future,” says Professor Martin Marshall, Chair of the Royal College of GPs. “We see more consultations every month than before the pandemic and the care we provide is becoming more complex, but the number of fully qualified, full-time GPs is falling.”
Christina Pagel, professor of operational research at University College London, says Covid-19 “made the NHS crisis considerably worse”, but did not cause it. “Essentially, we entered the pandemic with a health service that was already cut to the bone, with severe staff shortages, morale problems and underfunding.” Nigel Edwards, chief executive of the Nuffield Trust think tank, agrees. “The pandemic has added fuel to the fire, but the root of these problems has been there for decades.”
Dr Subramanian Narayanan, president of HCSA, the hospital doctors’ union, says the NHS is in a worse position to deal with a pandemic now than in 2020. “Staff shortages are more severe than in start of the pandemic and there is no evidence that the drivers of this are being addressed.”
The labor crisis is the main problem. “There have been warnings for years about the lack of a health workforce plan,” says Pagel. “Brexit made it much worse, especially in the cities, as we lost so many EU staff who decided to come home.”
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Pat Cullen, the general secretary of the Royal College of Nursing, which will vote its members on industrial action next month, says the key to solving the NHS crisis is through “recruitment and retention, and that it starts by paying staff fairly.”
In 2019, the government promised 6,000 more GPs by 2024, but progress has been glacially slow. Photograph: Hugh Hastings/Getty Images
With a renewed focus on ambulance delays and backlogs of care, other areas of the NHS are falling behind. Mental health is an alarming example. “Mental health, over the last few years, has come up on the agenda,” says McLellan. “And the standard of investment in mental health, while not perfect, saw more money being spent on mental health. Mental health was catching up … my feeling now is [it’s] actually going backwards.”
Saffron Cordery, the chief executive of NHS providers, says mental health services are overstretched. The Royal College of Psychiatrists warns that waiting lists are at record levels and care is at “crisis point”. The charity YoungMinds says thousands of young people are trying to kill themselves as a result of long waits for treatment.
“The NHS has never faced such a deep crisis and there seems to be no political will to face reality and deal with it,” says Boyle. “It is deeply concerning that neither the Prime Minister nor the leadership candidates have grasped the gravity of this crisis, the scale of the harm to patients and how much worse it could get in the winter.”
Since its absence from the Stoke-on-Trent debate, the NHS has barely featured in the leadership race. He did so recently when Truss said he would divert £13bn of NHS funding to social care.
It’s a good idea in theory, McLellan says, but it should have happened years ago. The problem is that now is a “dangerous time to do so.” “Does social care need more money than the NHS? Yes. But now we’re in a situation where they’ve let the NHS go into crisis and so has social care. So they both need money.”
Tough decisions have to be made, Edwards says. “The new Prime Minister will have to face up quickly and make tough decisions to address the interconnected challenges of health and care if she hopes to reverse declining performance, falling public satisfaction and growing inequalities of access” .
That means urgent action, Murray stresses. “What can be done? Winter is always by far the most difficult time for the NHS, and time is running out to do anything, but what can be done should be done.
“This includes following the vaccination campaigns against Covid and the flu; produce a quick fix to the pension problem driving senior staff out of service; and being ready for emergency support in social care which can also help the NHS by getting patients out of hospital quickly when they are ready. Beyond that, sustainable recovery can only come from addressing the workforce crisis.”
Hunt says: “We’re in for a horrendous winter, and a serious, funded NHS workforce plan is the only way to prevent preventable deaths piling up in the coming months.” Ede argues that urgent investment in NHS capital, such as new equipment and facilities, “has the potential to deliver a far greater return – solving problems such as delayed diagnosis”.
Meanwhile, the NHS crisis and the choices facing the new prime minister come at the worst possible time, Edwards says. “These decisions will be made…