The NHS’s winter crisis

The NHS often runs into trouble in winter, but things have never looked quite this bad. What’s gone wrong? Simon Wilson reports.

Isn’t there a crisis every year? 

Indeed. This year, however, the turmoil is of a different order: 27 December was the busiest day in the service’s history. Bed occupancy rates are the highest they have ever been at this stage of the year. Some 66 hospital trusts have issued emergency alerts over the winter.

The number of elderly patients waiting on trolleys has trebled, and waiting times in A&E have jumped dramatically. The Red Cross ramped up the political temperature by describing the situation as a “humanitarian disaster”. And then the chief of NHS England, Simon Stevens, flatly contradicted Theresa May’s assertion that the NHS had in fact received more money than it asked for.

What’s going on?

Much of the comment on the “winter crisis” in the NHS identifies the issue of “bed blocking” as a key challenge: deep cuts to social care mean that more people remain in hospital longer than they need to because there’s nowhere for them to go. That causes a ripple effect through the system that ends up with ambulance crews queuing in corridors for hours to get their patients into A&E.

People making unnecessary trips to A&E aren’t helping. The underlying cause of the health service’s complex woes, though, is relatively straightforward. Demand is soaring (by up to 5% a year), and so are costs (inflation in the NHS is around 7%, in part due to costly new medical advances). But funding has not kept pace.

Why is demand soaring?

The UK population is growing unusually fast compared with other rich nations, and we are also – crucially – ageing remarkably quickly. In 2015 there were more than three times as many people aged over 85 than there were just 25 years earlier. This boosts demand for two very costly types of healthcare. The first is looking after the terminally ill: about 25% of all hospital inpatient spending is on a patient’s last three months, according to data cited by The Economist.

The second is looking after people with more than one chronic condition – about 70% of all NHS spending is on long-term illnesses. More than half of over-70s have at least two such conditions.

But isn’t funding increasing?

The government rightly insists that NHS funding is still rising in real terms. But as a share of national income it is falling, and remains far lower than in comparable European countries (30% lower, per person, than Germany, for example). Spending has grown by an annual real average of 3.9% a year since the NHS was created in 1948. In the current decade (2010/2011-2020/2021), however, projected annual growth in spending will be just 0.9%. In the 2000s, when Labour began pumping money into healthcare – the bulk of it into wage bills – spending per patient soared by 70%.

In the present decade, it will scarcely budge. No other rich European country is going through a similarly rapid deceleration in funding, says the Health Foundation think tank. As a share of GDP, the UK’s spending on health was 7.3% (£134bn) last year, lower than most similar countries. It is projected to fall to 6.6% by 2021. If demand grows in line with NHS forecasts (and ignoring any efficiency savings), the NHS faces a shortfall in annual funding of about £20bn by 2020-2021.

Does the NHS do a good job?

It’s very good at some things. The NHS in England vaccinates more people against flu and screens more women for cancers than comparable countries, for example. But it compares badly on crucial international benchmarks such as survival rates from cancers, strokes and heart attacks.

There are several international studies suggesting that the NHS is relatively efficient compared with its European counterparts, but that overall its outcomes are worse. Even the one study often cited by defenders of its performance (a 2014 study by the Commonwealth Fund) found that its main relative weakness was “its poor record of keeping people alive” – not a minor concern for a health service.

What will happen next?

Maybe nothing. If the government decides that the current situation is politically tolerable, then the NHS may well be set for a period of decline in which it’s just about managing, with services deteriorating and the wealthiest patients bleeding off into the private sector. Alternatively, the government may opt for more funding, whether in the form of general taxation, a hypothecated health tax, or co-payments such as charging those who can afford to pay for GP visits (in the same way that NHS dentists have been charging for treatment since 1952).

A radical route would be to move to a social insurance model like those in Germany and the Netherlands. Private providers operate under strict government regulation, and everyone is obliged to buy health insurance, with the state covering those who can’t afford it.

  • Elliot Bridgewater

    Nice round-up 🙂

  • Quite an even-handed assessment, overall. It would be nice if the level of attention given to Labour’s increased healthcare spending was also given to the chronic underfunding that came before it under the Conservatives. It provides much-needed context for the current situation, but for some reason, the story told always seems to be one of Labour overspending and not Tory underfunding.

    The 2014 Commonwealth Fund report does seem to come at the issue with an axe to grind against the US healthcare system which, while not unreasonable (Americans have to pay for it twice, once out of taxation and once for their insurance premiums, and unless you can afford higher levels of cover, access and outcomes are ghastly), does result in the NHS getting an easy ride in some areas. It’s rather reductive to reduce the report for the poor ‘mortality amenable’ scores though, especially as that particular dataset is at least 10 years old at this point and considerable changes have occurred since then (MRSA and C. diff cases have become really quite rare, for starters). It’s true that there are some things the NHS doesn’t do as well as it perhaps should, though, and it’s not always clear why. Limited availability of the most expensive drugs does not account for all of the difference.

    The current crisis is frustrating in that it’s not really the NHS per se that’s at issue, but decades of neglect in health and social care. Hospitals are backed up because there’s nowhere for people to go once they’re ready to leave, or no resource to support them in their own homes. Rectify that and the NHS itself probably has the capacity to handle this particular surge.

    But that’s not enough, because our population is changing. It’s fashionable in some circles to blame immigrants, but the truth is the bulk of them are relatively healthy and don’t exert a lot of pressure on the system upward of primary care. The two big challenges we have are the increase in obesity levels, which means a corresponding surge in type 2 diabetes, and the ‘Boomer Bulge’, as that large post-war generation becomes elderly and infirm. I don’t think we’re going to be able to accommodate either without (a) putting our hands in our pockets and funding the NHS and health & social care at a level more appropriate for a nation of our standing, (b) continuing reforms and organisation changes within the NHS and (c) probably doing a lot less than we do now, with non-essential treatments becoming something people have to pay for privately.

    The NHS is a behemoth and behemoths are powerful, but they also lumber. Steps have been taken to make the NHS more agile (like the adoption of World Class Commissioning) but it could use a helping hand from government more often (to cut out practices like drug companies buying drugs off each other at inflated prices, so they can sell them on to the NHS at the inflated price and circumvent buying rules on markup levels). Most importantly of all, steering a behemoth requires smoothness and foresight. If you want to try and change direction, you need to have a really good idea of where you’re going. If you keep turning this way and that, don’t be surprised if you end up expending a lot of energy without changing very much at all.